COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX64131513 
RC81 6  .Ew1  The  diseases  of  the 


1^&6)G 


^\XS  \ 


THE 


DISEASES  OF  THE 
STOMACH 


BY 

Dr.   C.  a.   EWALD 

EXTRAORDINAET    PROFESSOR    OF    MEDICINE    AT   THE    UNIVERSITY    OF    BERLIN 
DIRECTOR    OF    THE    AUGUSTA    HOSPITAL,    ETC. 


AUTHORIZED  TRANSLATION  FROM  THE  SECOND  GERMAN  EDITION 
WITH  SPECIAL   ADDITIONS  BY   THE  AUTHOR 

By  morris   manges,  A.M.,  M.  D. 

ATTENDING    PHYSICIAN  TO    OUTDOOR   DEPARTMENT,    MOUNT    SINAI    HOSPITAL, 
NEW    YORK    CITY,    ETC. 


WITH  THIRTY  ILLUSTRATION'S 


NEW    YORK 
D.    APPLETON    AND    COMPANY 

1893 


Copyright,  1892, 
By  D.  APPLETON  AND  COMPANY. 


Electrotyped  and  Printed 

AT  THE  ApPLETON  PrESS,    U.  S.  A. 


AUTHOE'S  PEEFACE 
TO   THE  AMEEICAN  TEANSLATION. 


I  FEEL  liiglily  honored  that  the  Klinik  der  Yerdauungshrank- 
heiten  should  have  been  thought  worthy  of  being  independently 
rendered  into  English  on  both  sides  of  the  Atlantic  ;  for,  in  addi- 
tion to  the  present  translation  by  Dr.  Manges,  another  is  being 
issued  by  the  ISTew  Sydenham  Society  of  London. 

I  am  greatly  indebted  to  Dr.  Manges  for  the  excellent  manner 
in  which  he  has  performed  his  task.  At  the  same  time  I  wish  to 
state  that  I  have  carefully  read  his  manuscript,  and  have  made 
many  additions  to  it.  In  this  way  I  believe  I  have  included  the 
very  latest  investigations  on  this  subject.  Hence  the  volume  is 
not  merely  a  rendering  of  the  second  German  edition,  but  it  practi- 
cally represents  the  third  German  edition,  which  will  soon  appear. 

I  trust  that  the  work  will  meet  with  a  friendly  reception  among 
my  American  colleagues,  and  that  it  will  lead  to  further  investiga- 
tions in  this  interesting  and  difficult  field. 

C.    A.    EWALD. 

Berlin,  3Iarch  5,  1892. 

(3) 


TEANSLATOK'S  PEEFACE. 


The  present  work  represents  Yolume  II  of  Professor  Ewald's 
Klinik  der  Yerdauungshrankheiten,  a  treatise  whicii  has  been 
received  with  so  much  favor  abroad  that  two  editions  were  called 
for  within  nine  months,  and  translations  made  into  the  Russian, 
Italian,  and  Spanish  languages. 

I  have  not  included  "Volume  I,  since  it  has  already  been 
rendered  into  English  by  Dr.  Saundby.  A  second  edition  of  this 
part,  which  treats  of  the  physiology  of  digestion,  has  just  been 
issued  in  connection  with  the  English  translation  of  the  present 
volume  by  the  New  Sydenham  Society  of  London. 

The  two  parts  are  entirely  independent  of  each  other.  The  im- 
portant references  to  it  have  been  condensed  and  included  in  the 
translator's  foot-notes. 

The  numerous  additions  by  Professor  Ewald  have  not  been  spe- 
cially indicated,  as  this  would  have  interfered  with  the  unity  of  the 
work,  and  would,  moreover,  have  caused  unnecessary  confusion. 

The  new  matter  which  I  have  incorporated  into  the  text  and 
foot-notes  is  inclosed  in  [  ]. 

All  of  the  illustrations  have  been  redrawn,  while  some  have  also 
been  modified.  Figures  2,  5,  and  11  to  15  inclusive  have  been 
added  by  me. 

I  am  indebted  to  Dr.  L.  M.  Michaelis  for  assistance  in  the 
preparation  of  a  portion  of  the  work. 

M.  Manges. 

941  Madison  Avenue, 

New  York,  April  1,  1892. 

(4) 


PREFACE  TO  THE  FIRST  GERMAN  EDITION. 


The  following  lectures,  wliicli  are  intended  for  the  use  of  gen- 
eral practitioners,  are  based  upon  the  stenographic  reports  of  my 
remarks  at  the  Feriencurse  fur  praktische  Aerzte.  This  volume  is 
the  second  part  of  the  Klinik  der  VerdauungsTcranMieiten,  the 
first  part  of  which  discussed  the  physiology  of  digestion  in  its  prac- 
tical relations.  It  will  therefore  be  justifiable  to  simply  mention 
])riefly  and  give  the  final  results  of  many  subjects  which  have  been 
freely  discussed  during  the  past  few  years ;  for  the  general  prac- 
titioner desires  to  know,  not  the  source  of  discoveries,  but  their  final, 
acknowledged  results,  which  will  be  useful  to  him  at  the  bedside. 

It  may,  perhaps,  seem  hazardous  to  publish  these  lectures  now, 
at  a  time  when  this  branch  is  being  so  thoroughly  and  enthusiasti- 
cally investigated  with  new  methods,  that  almost  every  day  addi- 
tional results  are  being  published,  which  are  to  bring  us  nearer  to 
a  complete  understanding  of  the  difficult  and  complicated  problems 
of  the  pathology  of  the  stomach.  But  it  is  just  through  this  active 
rivalry  that  our  knowledge  of  the  subject  has  been  so  enriched  on 
the  one  hand,  and  on  the  other  so  cleared  up,  that  the  time  seems  to 
have  come  to  collect  these  facts  and  to  draw  general  conclusions 
from  them,  without  having  to  fear  lest  the  morrow  will  disprove 
what  we  have  taught  to-day. 

With  this  in  view  I  have  examined  what  has  been  accomplished 
in  the  past  few  years,  and  have  endeavored  to  separate  what  is  of 
permanent  value  from  that  which  is  merely  of  secondary  impor- 
tance. Since  many  points  are  still  undecided,  the  future  alone  can 
tell  how  far  I  may  have  succeeded  in  this  effort,  and  also  how  many 
of  the  factors  upon  which  we  now  depend  will  remain  undisputed. 

At  all  events,  wherever  it  was  possible,  I  have  endeavored  to  pass 

(5; 


vi  DISEASES   OF  THE   STOMACH. 

judgment  dispassionatelj  by  means  of  the  results  of  mj  personal  ex- 
amination, experience,  and  opinion.  But  nothing  is  better  adapted 
to  prevent  overvaluation  of  our  modern  acquisitions  than  a  study  of 
the  older  writers,  especially  those  of  the  first  half  of  the  present 
century,  in  the  literature  of  which  an  abundance  of  splendid  prac- 
tical observations  has  been  stored  up.  I  must  not  neglect,  however, 
to  acknowledge  to  what  great  extent  we  are  especially  indebted  to 
Kussmaul  and  Leube,  who  so  successfully  inaugurated  the  new  era  in 
the  investigations  on  the  diseases  of  the  stomach. 

In  these  lectures  no  attention  has  been  paid  to  the  digestive  dis- 
orders of  children,  in  so  far  as  they  occur  independently  and  pecul- 
iarly in  them  ;  neither  has  gastromalacia  been  considered  as  a  sepa- 
rate lesion — the  former,  because  there  is  no  lack  of  splendid  and 
complete  works  on  the  diseases  of  children ;  the  latter,  because 
softening  of  the  stomach  is  more  interesting  from  a  pathological 
standpoint  than  it  is  in  its  anatomical  aspects ;  while,  moreover,  its 
claims  to  be  included  among  the  diseases  of  the  stomach  seem  more 
than  doubtful. 

I  am  indebted  to  my  brother.  Prof.  Richard  Ewald,  of  Stras- 
burg,  for  the  comprehensive  review  of  the  innervation  of  the 
stomach. 

The  illustrations,  except  Vt^here  otherwise  stated,  have  been  drawn 
by  myself  from  original  specimens. 

May  this,  the  second  and  pathological  po^^tion  of  the  KliniJc  der 
Verdamingskrmikheiten,  enjoy  the  same  friendly  and  favorable  re- 
ception which  was  accorded  to  the  first  part !  This  would  lie  an  in- 
ducement to  me  to  publish  at  an  early  date  the  third  part,  which 

shall  treat  of  the  diseases  of  the  intestines.  ^     .    _^ 

C.  A.  Ewald. 

Berlin,  WMtsuntide,  1SS8. 


CONTENTS 


LECTURE   I. 

PAGE 

Methods  of  Exajiination.    Determination  of  the  Acidity  and  Acids    of 
THE  Contents  op  the  Stomach 1 

Examination  of  the  functions  of  the  stomach.  The  stomach-tube.  Mode  of  in- 
troduction.— Ewald's  method  of  exi^ression.  Its  advantages.  Absence  of  danger 
in  exploration  of  the  stomach  with  the  soft  tube. — Test-breakfast  and  test-dinner. 
Composition  of  the  stomach-contents  during  the  first  hour  after  taking  the  test- 
breakfast. — Determination  of  the  acidity  ("titration  method). — Demonstration  of 
free  acid  in  the  stomach-contents  with :  (1)  tropteolin  ;  (2)  Congo-red;  (3)  benzo- 
purpurin.  Detection  of  hydrochloric  acid  with  the  aniline  dyes ;  Mohr's  reagent ; 
Giinzburg's  reagent  (phloroglucin-vanillin) ;  Boas's  reagent  (resorcin). — Demon- 
stration of  lactic  acid  in  the  stomach-contents  (Uffelmann).  Extraction  with 
ether. — Demonstration  of  the  fatty  acids  (butyric  acid).  Acetic  acid  and  alcohol 
in  the  stomach-contents. — Quantitative  estimation  of  free  and  loosely  combined 
hydrochloric  acid  (Mintz,  SjOqvist,  Ilayem,  and  Winter). 

LECTURE   IL 

Methods   of   Examination  {continued).    Determination   of  the  Digestion 
of  Albumen  and  Starch.     Absorption  and  Motility.     The  Technique 

of  the  Examination  of  the  Stomach 41 

Eelations  and  reactions  of  albumen  and  albuminoids.  Their  value  in  the  prac- 
tical examination  of  the  stomach-contents.  Formation  of  propeptone  and  peptone 
during  digestion.  Digestion  by  pepsin  and  hydrochloric  acid  (proteolysis). 
Methods  of  testing, — Kennet  (Labferment).  Eennet-zymogen. — Saliva:  its  action 
on  the  starches.  Sacchariiication. — Testing  the  absorptive  powers  of  the  stomach 
(Penzoldt,  iodide  of  potassium). — Motor  function  of  the  stomach ;  salol  test 
(Sievers,  Ewald,  and  Huber).  Oil  test  (Klemperer). — Bile  in  the  stomach-con- 
tents.— Physical  examination  of  the  stomach  :  (1)  palpation  ;  (2)  distention  of  the 
stomach  and  intestines  with  air  (von  Frerichs,  Euneberg) ;  (3)  filling  the  stomach 
with  water  (Piorry,  Penzoldt) ;  (4)  murmurs  of  deglutition  ((SWi.?«c%emMsc7ie). — 
Gastroscope.  Gastrodiaphane. — Technique  of  the  treatment  of  the  diseases  of  the 
stomach;  washing  out,  electrization,  massage,  and  hydrotherapy  of  the  stomach. 
— Priority  in  the  use  of  aniline  dyes  for  detecting  free  acids  in  the  stomach- 
contents. 

LECTURE   IIL 

The  Stenoses  and  Strictures  of  the  Cardiac  Orifice  of  the  Stomach  .  71 
Stenoses  due  to  spastic  contraction  or  cicatricial  tissue  or  neoplasms.  General 
symptoms  of  stricture  of  the  cardia.  Consecutive  dilatation  of  the  lower  segment 
of  the  cesophagus.  Vomiting.  Contents  of  the  vomit. — Sounding  the  oesophagus. 
(Esophageal  probang  and  sounds. — Stricture  of  the  cardia  due  to  spastic  contrac- 
tion of  the  sesophagus.     Symptoms.— Stricture  of  the  cardia  due  to  cicatrices  and 


viii  DISEASES  OP  THE  STOMACH. 

PAGB 

neoplasms,  (a)  which  exert  pressure  from  without  (tumors  of  the  mediastinum 
and  retroperitonreum  and  aortic  aneurisms),  (/3)  which  involve  the  entrance  to  the 
stomach  and  stenose  it. — Dilatation  of  the  oesophagus  above  the  stenosis.  Pressure 
and  traction  diverticula ;  simple  ectasia.  Case  of  carcinoma  of  cardia  which  was 
operated,  with  report  of  autopsy.— Treatment  of  strictures  at  the  cardia :  passing 
bougies ;  permanent  canulse  and  tubes ;  gastrostomy  (description  of  operation  by  - 
Sonnenburg).  Feeding  of  the  patient;  nutrient  eneniata;  diet  after  formation  of 
a  gastric  fistula. 

LECTURE  IV. 

The  Stenoses   and   Strictures    of   the   Pylorus.    Megastria   and   Gas- 

TRECTASIA.      DILATATION   OF  THE   StOMACH 110 

Plaster  models  of  stomach  (demonstration).  Diagnosis  of  large  and  of  dilated 
stomachs.  Inspection ;  percussion  ;  palpation  (ot  the  tip  of  the  sound,  Leube) ; 
auscultation  (succussion,  deglutition-murmurs,  Eosenbach's  method) ;  measuring 
capacity  of  the  stomach  (filling  with  water). — Etiology  of  dilatation  of  stomach. 
I.  Mechanical  narrowing  or  closure  of  pylorus  (a)  in  the  walls  of  the  stomach 
themselves,  (^)  extending  by  continuity  from  without),  a.  Cancerous  tumor ; 
cicatricial  stenosis  ;  congenital  narrowness  of  the  pylorus ;  bending  of  the  duode- 
num toward  the  pylorus  ;  spastic  contractions  of  the  pylorus.  5,  Tumors  which 
press  on  or  surround  the  pylorus  growing  from  the  pancreas,  liver,  omentum,  or 
the  glands.  Kelations  of  wandering  kidney  to  dilatation  of  the  stomach.  II. 
Dilatation  of  the  stomach  due  to  weakness  of  the  muscles  of  the  stomach  (atonic 
gastrectasis).  a,  Enfeebled  tone  of  the  muscular  fibers ;  5,  weakness  and  paralysis 
of  the  motor  nerves  of  the  stomach  ;  c,  exclusion  of  localized  areas  of  the  muscular 
fibers  of  the  stomach. — Pathological  anatomy  of  the  dilated  stomach. — Symptoms 
of  gastrectasis.  Insufficiency  of  the  stomach.  Micro-organisms  in  the  stomach. 
Chemical  relations  of  the  gastric  juice.  Slowing  of  absorption  and  motion  of  the 
stomach.  Peristaltic  unrest  of  the  stomach  (Kussmaul).  Pityriasis  of  the  skin. 
Muscular  spasms.  Tetany.  Relations  of  the  urine. — Diagnosis  of  gasti*eetasis. — 
Course  and  prognosis. — Treatment.  Diet.  Withdrawal  of  fiuids.  Peptone  prepa- 
rations and  peptonized  milk.  Nutrient  enemata.  Drugs.  Prevention  of  stagna- 
tion of  the  contents  of  the  stomach.  Lavage.  Massage  and  electricity  to  the 
stomach.  Operative  dilatation  or  excision  of  the  stenosis.  Demonstration  of  sev- 
eral patients  with  gastrectasis. 

LECTURE  V. 

Cancer  of  the  Stomach 1 C2 

Statistics.  Sex.  Heredity.  Causes.  Traumatisms,  chronic  ulcer  of  stomach. 
— Pathological  anatomy  :  scirrhus,  medullary,  colloid,  villous,  and  telangiectatic 
varieties.  Localized  tumors  and  diffuse  cancerous  infiltration. — Site. — Sequel£e  of 
cancer  of  the  stomach:  diminution  in  size,  dilatation  of,  changes  in  site,  ti'action 
on,  bending  and  constriction  of  the  stomach. — Primary  and  secondary  gastric 
cancer.  Propagation  of  cancer.  Thi-ombosis.  Swelling  of  the  lymphatic  glands, 
ulceration,  perforation. — Symptoms  of  gastric  cancer.  Course  and  duration.  Ex- 
ceptions to  normal  course.  Statistics  of  individual  symptoms. — Diagnosis  :  (1) 
Absence  of  free  hydrochloric  acid  in  the  stomach -contents,  and  its  presence  even 
up  to  the  death  of  the  patient.  Relations  of  pepsin  and  rennet.  Presence  of  other 
acids  in  place  of  or  along  with  hydrochloric  acid.  (2)  Specific  tissue-elements 
in  the  vomit  or  in  masses  evacuated  through  the  tube.  The  mistaking  of  cancer- 
ous cell-nests  and  epithelial  shreds  of  the  mucous  membrane.  (3)  The  cancerous 
tumor  (differential  diagnosis  from  tumors,  etc.,  of  other  organs,  and  fecal  masses). 
Pain  in  the  tumor.  (4)  Cancerous  cachexia  (hysterical  cachexia). — Dittereutial 
diagnosis  between  cancer  and  ulcer  of  stomach,  severe  gastric  catarrh,  atrophy, 
amyloid  degeneration  of  the  mucous  membrane  of  stomach,  severe  hysteria  and 
neurasthenia. — Treatment.     Condurango  bark.     Symptomatic  treatment   of  pain, 


CONTENTS.  ix 


vomiting  and  constipation.     Diet.     Treatment  at  mineral  springs. — The  non-can 
cerous  tumors  of  the  stomach. 


PAGE 


LECTURE    VI. 
Ulcer  of  the  Stomach.    Ulcus  Pepticum  seu  Rodens 217 

Chronic  round  ulcer  of  the  stomach.  Origin. — Experiments  on  animals.  Dis- 
proportion between  the  acidity  of  the  gastric  juice  and  the  condition  of  the  blood. 
Hyperacidity  of  the  gastric  juice  in  ulcer.  Theories  and  views  of  various  investi- 
gators.— Frequency  of  ulcer.  Nutrition,  sex,  and  age  of  patient.  Situation  of 
ulcer.  Frequency  of  perforation. — Pathological  anatomy.  Htemorrhagic  infarc- 
tion of  the  mucous  membrane.  Appearance  under  the  microscope  of  sections 
through  the  edge  of  the  ulcer.  Fallacy  of  Witosowski's  theory.  Form  and  struct- 
ure of  the  ulcer.  JResult  of  the  ulcerative  (necrotic)  process  in  (1)  cicatrization  ; 
(2)  progressive  necrosis  terminating  in  (a)  corrosion  of  the  blood-vessels,  (/3) 
adhesions  to  adjacent  viscera  and  perforation. — Tubercular  and  syphilitic  ulcers 
of  the  stomach. — Symptoms  of  gastric  ulcer:  (1)  cases  with  marked  symptoms  of 
irritation  without  further  complications;  (2)  cases  with  symptoms  of  irritation 
and  hasmorrhages ;  (3)  cases  with  symptoms  of  irritation  and  perforation  (re- 
covery or  death) ;  (4)  cases  which  run  a  latent  course  up  to  death. — Gastralgia, 
conditions  of  the  bowels,  state  of  nutrition,  vomiting,  heemorrhages  in  the  stomach, 
perforation  and  extension  into  neighboring  viscera,  perforation  peritonitis. 
Prognosis  of  perforation.  Cicatrization. — Differential  diagnosis :  syphilis  and 
ulcer,  tuberculosis  and  ulcer.  Scheme  of  diagnosis  of  nervous  gastralgia,  ulcer, 
and  cancer.  Use  of  stomach-tube  in  ulcer.  Biliary  colic  and  gastralgia  due  to 
ulcer  of  stomach.  Situation  of  ulcer  in  .stomach  and  duodenum. — Prognosis, 
treatment.  Kest-cure.  Carlsbad  water.  Nutrition  and  diet.  Iron,  arsenic, 
bismuth,  nitrate  of  silver,  milk.  Alleviation  of  pain,  vomiting,  and  gastric 
haemorrhage.  Treatment  of  collapse  and  perforation  pei-itonitis.  Operation  (ex- 
cision) of  the  ulcer.     Treatment  of  ulcer  at  the  mineral  springs. 

Appendix,  page  276. — Htematemesis.  Difterentiation  of  harnoptysis  and  hjema- 
temesis.  Causes  of  the  latter :  (1)  venous  congestion ;  (2)  active  hypersemia  ;  (3) 
traumatisms ;  (4)  changes  in  the  walls  of  the  vessels. 


LECTURE  Vn. 

The  Inflammations  of  the  Coats  of  the  Stomach.  Gastritis  Glandu- 
laris Acuta,  Idiopathica  et  Sympathica.  Gastritis  Phlegmonosa 
Purulenta — Gastritis  Toxica 281 

Mutual  relations  of  absorption,  motion,  and  secretion  of  the  stomach  ;  also  of  the 
affections  of  the  stomach  and  those  of  the  liver  audi  ntestines. — Acute  gastritis. 
Etiology  (mechanical,  chemical,  and  thermal  initants). — Pathological  anatomy. 
The  normal  mucous  membrane  of  the  stomach  which  has  been  placed  in  alcohol 
immediately  after  death. — Symptoms :  afebrile  and  febrile  catarrh.  Diagnosis. 
Kelations  of  tongue. — Difterential  diagnosis  (incipient  typhoid  fever,  meningitis, 
peritonitis,  hepatitis,  biliary  colic). — Treatment. — Gastritis  sympathica  acuta.  Oc- 
currence in  acute  febrile  diseases  (gastritis  diphtheritica).  Tenninations. — Gastritis 
phlegmonosa  purulenta.  Occurrence  and  etiology.  Idiopathic  and  metastatic 
varieties. — Pathological  anatomy  (abscess  of  stoiuach  and  diffuse  purulent  infiltra- 
tion). Symptoms.  Diagnosis.  Treatment. — Gastritis  mykotica.  Bacillus  gastri- 
cus.  Anthrax,  maggots. — Gastritis  toxica.  Alcohol,  phosphorus,  corrosive  poisons. 
Acute  poisonings. — Treatment.  Emptying  of  stomach  with  stomach-tube  and 
washing  out.     Neutralization  of  the  poison. 


DISEASES   OF   THE   STOMACH. 


LECTURE   VIII. 

PAGE 

Gastritis  Glandularis  Chronica.     Chronic  Catarrh  of  Stomach.     Atro- 
phy OF  the  Stomach 313 

General  conceptions  (dyspepsia,  chronic  inflammatory  condition  of  the  glands 
and  the  influence  of  the  nerves  on  the  same). — Pathological  anatomy  :  paren- 
chymatous and  interstitial  inflammation  of  the  mucous  membrane.  The  mucoid 
degeneration  of  the  grandular  cells  which  may  be  observed  even  to  the  base  of 
the  glands  in  very  fresh  specimen.  Transition  of  chronic  gastritis  into  atrophy 
of  the  mucous  membrane  ;  the  parenchymatous  and  the  interstitial  forms,  the 
former  proceeding  from  above  do  vvnward,  the  latter  from  below  upward  (cirrhosis 
or  sclerosis  ventriculi).  Phthisis  ventriculi,  terminating  in  anadenia  of  the 
stomach.  Polypi  of  the  gastric  mvicosa. — Etiology  of  chronic  gastritis.  Develop- 
ment from  the  acute  form :  processes  which  produce  venous  congestion  of  the 
stomach  ;  exhausting  diseases  ;  direct  local  irritants  (insutficiently  chewed  mor- 
sels, improper  care  of  mouth  and  teeth,  abuse  of  alcohol  and  tobacco,  etc.). — 
Symptoms.  Gastritis  chronica  simplex  and  mucosa  (termination  in  phthisis  or 
anadenia  of  the  stomach).  Chronic  dyspepsia,  pyrosis,  cardialgia,  vomiting, 
gastrectasis.  Bowels.  General  symptoms :  "  stomach-cough,"  asthma  dyspepti- 
cum,  vertigo,  agoraphobia. — Atony  of  the  stomach. — Phthisis  and  anadenia  of  the 
stomach.  Vicarious  digestion  by  the  intestines.  Eesemblance  to  progressive 
pernicious  anemia.  Age  of  the  patients  with  gastric  phthisis. — Diagnosis  (simple 
and  mucous  gastritis,  anadenia). — Ditlerential  diagnosis  between  anadenia,  neu- 
roses, and  carcinoma  of  the  stomach. — Course  and  pi-ognosis. — Treatment.  Pep- 
togenous  substances,  hydrochloric  acid  and  pepsin.  Washing  of  the  stomach. 
Bitters.  Diet  (care  of  teeth  and  slow  eating).  Food  and  drink  allowed  and 
to  be  avoided.  General  relations.  Treatment  of  fermentation  in  stomach  (lav- 
age, antifermentatives).    Gastralgia.     Purgatives.     Enemata.    Mineral  waters. 

LECTURE   IX. 

The   Neuroses   of   the    Stomach.    The   Physiological   Relations  of  the 

Stomach 363 

Functional  disturbances  of  the  stomach.  Description  of  the  innervation  of  the 
stomach  (Eichard  Ewald).  General  relations  between  the  functions  of  the 
stomach  and  the  nervous  system.  Anatomy  of  the  vagus  and  sympathetic  nerves 
and  ganglion-cells.  —  Absorption.  —  Vaso-motor  relations.  —  Movements  of  the 
stomach ;  peristalsis  and  anti-peristalsis.  Muscles  of  the  stomach  ;  opening  and 
closing  of  the  cardiac  and  pyloric  orifices.— Vomiting  ;  its  origin.— Sensitiveness  of 
the  organ  and  its  abnormal  increase.— Hunger  ;  sensation,  and  its  center.  Locali- 
zation of  the  sensation  of  hunger ;  its  central  situation.  Satiation.  Appetite  and 
its  relation  to  hunger.     The  taking  of  food. 


LECTURE   X. 

The  Neuroses  op  the  Stomach  {contimied) 387 

Classification.  Occurrence.  Sex.  Habit.  Situation  and  occupation  of  these 
patients.  General  nervous  symptoms  :  (1)  Conditions  of  irritation. — Hyperesthesia 
of  the  stomach.  Nausea.  Differential  diagnosis  from  the  organic  disorders  of  the 
stomach.  Symptoms.  Idiosyncrasies.  Varieties  of  the  sensation  of  hunger. 
Emptiness  of  the  stomach.  Bulimia.  Perverse  appetite.  Anorexia.  Gastralgia ; 
genuine  gastralgia  as  the  result  of  diseases  of  central  nervous  system  ;  of  constitu- 
tional disorders.  Neurasthenic  gastralgia  (irritative  and  depressive  varieties). 
Painful  points  (Burkart).  Hysterical  gastralgia.  Symptoms.  Gastralgia  in 
Psychoses. 


CONTENTS.  xi 


LECTURE  XI. 

PAGE 

The  Neuroses  of  the  Stomach  {continued)      ,        .        ,        »        .        .        ,  414 

Conditions  of  irritation  (continued).  Hyperacidity  and  hypersecretion  of  the 
gastric  juice.  Definition  and  difference.  Periodical  and  continuous  flow  of 
gastric  juice.  Diagnosis.  Gastroxynsis.  Eructation.  Pyrosis.  Pneumatosis. 
Nervous  vomiting.  Periodical  vomiting  (Leyden).  Cramps  of  stomach.  Peri- 
staltic unrest  of  stomach  (Kussmaul). — (2)  Conditions  of  depression. — Ansesthesia 
of  stomach.  Polyphagia.  Nervous  anacidity  of  the  gastric  juice.  Paresis  of  the 
cardiac  orifice.  Eegurgitation.  Eumination ;  explanatory  theories.  Incontinence 
of  the  pylorus.  Atony  of  the  stomach. — (3)  Mixed  form.  Neurasthenia  gastrica 
or  vago-sympathica.  Conception  and  nature.  Views  of  various  writers  (Jurgens, 
Discovery  of  Degeneration  of  Meissner's  and  of  Auer bach's  Plexuses  in  the  Intes- 
tines). Etiology.  Special  symptoms.  Burkart's  painful  points,  gastralgia,  vomit- 
ing, stools.  Differential  diagnosis  (Leube's  test  of  digestion).  Prognosis.  Treat- 
ment.— (4)  Eefle.xes  from  other  organs :  (a)  mild  disturbances  of  digestion ;  {b) 
gastralgias ;  (c)  vomiting,  in  atfections  of  the  brain  and  of  spinal  cord  (gastric 
crises).  Vomiting  in  abscesses  and  calculi  in  the  liver  and  kidneys,  in  pregnant 
women,  injuries  to  the  uterus,  operations  on  the  bladder  and  urethra,  etc.  Dyspep- 
sia in  chronic  diseases  of  the  sexual  organs.  Reflexes  from  the  intestines  (neo- 
plasms, enteroliths,  parasites). — Treatment  of  the  gastric  neuroses. — Local  reme- 
dies. Sedatives  and  narcotics.  Chloroform-water,  constant  current,  massage  of 
stomach,  stomach-douche,  Neptune's  girdle.  Derivatives.  —  General  remedies. 
Preparations  of  bromine  and  bromide-water,  antipyrin,  pilocarpine,  phystostig- 
mine,  caffeine,  preparations  of  arsenic  and  iron  and  hydrotherapy.  Weir  Mitchell- 
Playfair  rest-cure.  Critique  of  this  method.  An  example  of  it  with  study  of  the 
metabolism.    Importance  of  systematic  weighing.     Treatment  at  mineral  springs. 

LECTURE  XIL 

The   Correlation   of   the   Diseases   of  the   Stomach  to  those  of  other 
Organs.    The  Practical  Value  of  the  Modern  Chemical  Tests        ,  463 

General  considerations. — Dyspeptic  disturbances  and  changes  in  digestion  in 
tuberculosis  (chemical  changes  in  the  gastric  juice  in  tuberculosis),  in  valvular 
diseases  of  the  heart,  in  diseases  of  the  kidneys,  liver,  and  central  nervous  system, 
diabetes,  gout,  and  rheumatic  diathesis. — Closing  remarks.  Value  of  the  modern 
methods  of  examination  of  the  stomach.  Untimely  occurrence  of  organic  acids 
(especially  lactic  acid),  changes  in  the  actual  digestive  juice.  Lessening  of  the 
production  of  hydrochloric  acid  in  changes  or  destruction  of  the  glandular  paren- 
chyma of  the  stomach.  Lessening  of  the  production  of  hydrochloric  acid  in 
persons  without  stomach  troubles.  Secretion  of  hydrochloric  acid  in  normal 
digestion.    Diagnostic  value  of  the  estimation  of  the  acidity  of  the  gastric  juice. 

Index 483 


LIST   OF   ILLUSTRATIONS. 


PAGE 

1.  Lower  end  of  Ewald's  stomach-tube 7 

2.  Curling  over  of  flexible  tube  in  the  stomach 11 

3.  Boas's  bulb  for  suction  of  stomach-contents 13 

4.  Stand  for  funnel  of  stomach-tube 64 

5.  [Auto-lavage  of  stomach.] 65 

6.  Ein horn's  deglutable  electrode 66 

7.  Carcinoma  surrounding  cardia,  side  view 79' 

8.  Carcinoma  surrounding  cardia,  front  view 80 

9.  Localized  carcinoma  of  cai'dia 87 

10,  Carcinoma  of  oesophagus  just  above  cardia 94 

11.  [Cast  of  cylindi'iform  stomach  in  vertical  position] 110 

13.  [Cast  of  normal  stomach] 110 

13.  [Cast  of  dilated  stomach  in  vertical  position] 110 

14.  [Cast  of  marked  dilated  stomach  tending  to  assume  vertical  position].         .  Ill 

15.  [Stomach  in  vertical  position.     In  sihi] 117 

16.  Very  vascular,  polypoid  tumor  on  posterior  wall  of  stomach        .         .         .  124 

17.  Carcinoma  of  pylorus  with  dilatation  of  stomach  and  duodenum        .         .  126 

18.  Cross-section  through  the  mucous  membrane  of  a  dilated  stomach        .        .  135 

19.  Scirrhus  ventriculi  totalis 172 

20.  Carcinoma  of  the  cardia.     Contraction  of  the  stomach 174 

21.  Vomit  from  a  case  of  carcinoma  of  the  stomach     .         .         .         .         .         .  179 

22.  Colloid  cancer  of  lesser  curvature  of  stomach 184 

23.  Cancerous  cell-nest  raised  through  stomach-tube 196 

24.  Piece  of  gastric  mucosa  resembling  cancerous  cell-nest 197 

25.  Perforating  ulcer  of  stomach 219 

26.  Piece  of  gastric  mucosa  raised  after  lavage  of  empty  stomach       .         .         .317 

27.  Section  of  mucosa  from  the  vicinity  of  a  resected  pyloric  cancer  .         .         .  318 

28.  Anadenia  of  stomach  with  accompanying  dilatation 319 

29.  Phthisis  ventriculi,  with  cirrhotic  atrophy 321 

30.  Total  atrophic  sclerosis  of  gastric  mucosa 322 

(13) 


DISEASES  OF  THE  STOMACH. 


LECTURE  I. 

METHODS    OF    EXAMINATION. DETERMINATION    OF   THE    ACIDITY   AND 

ACIDS    OF    THE    CONTENTS    OF    THE    STOMACH. 

Gentlemen  :  In  undertaking  to  discuss  tlie  diseases  of  the  digest- 
ive tract  in  the  following  lectures,  I  must,  at  tlie  beginning,  impose 
definite  limits  upon  myself,  and  must  refrain  from  attempting  to 
exhaust  the  entire  subject.  If  I  attempted  to  speak  of  everything 
which  lay  within  the  extensive  province  of  the  diseases  of  the  digest- 
ive tract  and  its  adnexa,  I  would  go  far  beyond  the  limits  of  these 
lectures,  and  individual  facts  would  be  slighted  at  the  cost  of  the 
whole.  The  diseases  of  the  mouth,  oesoj^hagus,  and  of  those  organs 
which,  like  the  spleen  and  liver  (although  closely  connected  with 
the  intestinal  tract  through  the  portal  vein),  display  no  true  or 
exclusive  digestive  activity,  will  be  treated  only  in  so  far  as  they 
directly  influence  the  functions  of  the  stomach  and  intestines,  and 
the  normal  or  abnormal  action  of  which  is  not  to  be  distinguished 
therefrom.  I  shall,  therefore,  mainly  confine  myself  to  the  diseases 
of  the  stomach  and  intestines,  and  shall  thus  follow  the  universal 
custom,  Avhich,  although  improperly,  generally  includes  only  the 
affections  of  these  two  organs,  under  the  expression,  Diseases  of 
Digestion. 

But  you  must  not  expect  these  lectures  to  be  a  systematic,  con- 
secutive, and  finished  text-book.  Our  literature  contains  not  a  few 
splendid  works  of  this  character  which  treat  this  theme  in  an  excel- 
lent and  exhaustive  way.  In  the  following  pages  I  wish  to  empha- 
size this  difference  between  a  text-book  and  a  series  of  lectures,  both 
in  the  form  and  in  the  subject-matter.  The  text-book  must  system- 
atize the  pathological  processes,  must  classify  them  nosologically. 


2  DISEASES  OP  THE  STOMACH. 

and  from  the  sum  of  individual  observations  and  facts  must  con- 
struct tlie  so-called  "  tjpical  case "  of  tlie  various  forms  of  disease. 
I  shall  take  a  more  modest,  I  might  almost  saj  a  more  intimate, 
point  of  view.  I  too  shall  make  use  of  my  material  to  delineate 
general  pictures  of  disease,  but  as  far  as  possible  I  wish  to  restrict 
myself  to  distinct,  personally  observed,  and  characteristic  cases ;  to 
lay  stress  on  the  special  features  of  individual  cases  which  impress  a 
distinct  character  upon  them ;  to  show  their  relation  to  the  gener- 
ally acee|)ted  facts ;  and  at  the  same  time  I  desire  to  exjjress  my 
personal  views  on  the  subjects  at  issue. 

I  should  incur  the  reproach  of  dealing  in  commonplaces  were  I 
to  emphasize  how  much  of  this  is  due  to  the  acquisitions  of  my  own 
experience,  including  the  results  of  both  personal  observation  and 
reading  and  study.  Accordingly,  if  I  should  fail  to  quote  every- 
thing and  anything  that  the  industry  of  recent  years  has  yielded, 
you  will  ascribe  such  omissions  to  my  desire  to  avoid  all  superflu- 
ous literary  ballast  which  is  nowadays  so  easily  paraded.  That  any- 
thing of  importance  has  escaped  my  notice  is  hardly  possible. 

But  you,  gentlemen,  who,  in  renewing  your  attendance  at  lect- 
ures and  hospitals,  bring  with  you  a  riper  experience  and  an  acuter 
judgment  than  the  students  in  their  first  "  semestres,"  what  can  be 
more  to  your  purpose  than  to  obtain  and  make  use  of  the  personal 
experiences  of  your  lecturer  as  much  as  possible,  and  to  profit 
thereby  in  proportion  as  you  are  able  to  criticise  them  by  means 
of  the  knowledge  already  acquired  in  practice  ?  ^^  I  trust  I  may 
succeed  in  presenting  to  you  in  a  suggestive  way  both  what  is 
already  well  known  as  well  as  what  is  novel. 

The  diagnosis  of  the  diseases  of  the  stomach  is  based,  as  in  other 
organs,  subjectively  upon  the  statements  of  the  patient,  and  object- 
ively upon  the  results  of  our  examination.  I  shall  disregard  the 
former,  as  this  will  be  discussed  in  the  description  of  each  disease. 
For  the  latter  we  may  utilize,  first,  the  so-called  methods  of  j^hysical 

*  [This  course  of  lectures  was  delivered  at  the  Feriencurse  fur  practisclie  Aerzte 
at  Berlin.  This  is  a  series  of  post-graduate  lectures  given  in  April  and  September 
of  each  year  by  the  extraordinary  professors  and  privat-docenten  of  the  Uni- 
versity of  Berlin.  They  last  one  month,  and  precede  the  opening  of  the  regular 
term.— Tr.] 


METHODS  OF  EXAMINATION".  3 

examination — i.  e.,  insjDection,  palpation,  auscultation,  and  mensu- 
ration ;  secondly,  ilie  analysis  of  the  chemical^  absorptive,  and 
motor  functions  of  the  organ — in  short,  the  investigation  of  the 
digestive  activity  of  the  stomach. 

The  physical  methods  are  so  well  known  that  they  may  be  sum- 
marily dismissed,  and  we  may  at  once  pass  to  the  consideration  of 
the  examination  of  the  functions  of  the  stomach.  Although  it  is 
part  of  my  task  to  discuss  the  pathology  of  the  stomach,  it  is  never- 
theless obvious  that  pathological  deviations  from  the  normal  can 
only  be  recognized  and  properly  treated  after  the  normal  condi- 
tions are  thoroughly  understood  ;  hence  I  must  also  briefly  consider 
this  topic.  Formerly  this  was  hardly  possible,  so  long  as  we  were 
restricted  to  the  inadequate  external  signs  and  the  subjective  com- 
plaints of  the  patients ;  but  now  a  very  important  factor  in  the 
methods  of  examination  has  been  supplied  since  we  have  learned  to 
obtain  the  contents  of  the  stomach  at  any  time  in  an  easy  and 
rapid  way,  Avhich  is  also  convenient  and  safe  to  the  patient. 

This  is  accomplished  by  means  of  the  hard  or  soft  stomach- 
tubes,  and  with  the  general  use  of  these  instruments  the  new  era  in 
the  pathology  of  the  diseases  of  the  stomach  began. 

Before  entering  into  the  discussion  of  our  theme,  permit  me  to 
make  a  few  brief  introductory  remarks.  The  methods  which  have 
recently  enabled  us  to  obtain  a  better  knowledge  of  the  chemical 
processes  in  the  stomach  have  thrown  a  light  upon  the  pathology 
of  dyspepsia  and  the  irregularities  of  gastric  digestion  which  is 
analogous,  comparing  a  small  matter  with  a  great  one,  to  what  the 
ophthalmoscope  did  in  its  day  for  the  retina,  and  the  laryngoscope 
for  the  interior  of  the  larynx.  It  was  inevitable  that  this  method 
should  soon  be  favorably  received,  and  that  it  should  have  been 
very  extensively  used  during  the  past  few  years  in  hospital  and 
general  practice.  I  wish,  however,  to  warn  you  not  to  lay  too 
much  stress  upon  these  procedures  as  belonging  to  a  specialty. 
During  the  course  of  these  lectures  you  will  be  enabled  to  con- 
vince yourselves  that  the  technique  of  the  methods  which  are 
in  use  is  by  no  means  difficult  to  carry  out,  and  is  within  the  scope 
of  every  physician  who  as  a  student  has  learned  to  titrate,  to 
test  acid  and  alkaline  solutions,  and  to  place  a  test-tube  in  a  warm 


4  DISEASES  OP  THE  STOMACH, 

chamber.  N^aturally,  fewer  persons  are  engaged  in  original  inves- 
tigations. Hence  the  examinations  do  not  require  the  skill  char- 
acteristic of  a  S23ecialty,  which  can  only  be  acquired  after  continu- 
ous occupation  with  that  specialty.  But,  to  obtain  and  analyze 
stomach-contents  do  not  lie  beyond  the  scope  of  the  dexterity  and 
ability  which  every  physician  ought  to  possess.  It  may  happen 
that  one  is  consulted  especially  by  patients  with  stomach  troubles 
because  he  has  occupied  himself  chiefly  with  the  study  of  these 
conditions,  and  has  hence  acquired  the  reputation  of  possessing  a 
special  experience.  But  this  alone  is  not  sufficient.  Physicians 
and  the  public  are  here  influenced  not  by  the  special  but  by  general 
medical  knowledge ;  this  is  certainly  not  acquired  if  a  23hysician 
immediately  after  graduation  sets  himself  up  as  a  sijecialist  for 
stomach  diseases.  In  the  course  of  these  lectures  you  will  see  how 
closely  the  diseases  of  the  stomach  are  related  to  those  of  other 
organs,  how  complicated  this  relation  is,  how  often  the  symptoms 
are  deceptive,  how  frequently  in  an  apparent  stomach  disorder 
entirely  different  organs  are  really  involved  !  Hence  it  is  ray  flrm 
conviction  that  it  is  im]30ssible  to  find  truly  profitable  and  satis- 
factory special  occupation  in  the  treatment  of  the  diseases  of  the 
stomach  alone,  because  the  field  is  too  small  and  the  technique  is 
so  easily  learned  and  is  so  limited  in  its  scope.  I  wished  to  premise 
these  remarks  because  such  questions  are  frequently  put  to  me. 

It  is  worthy  of  note  that  the  use  of  the  stomach-tube  is  by  no 
means,  as  is  supposed,  a  recent  acquisition.*  We  may  disregard 
the  crude  manipulations  of  Fabricius  ab  Aquapendente  and  Eum- 
saeus  (1659),  who  discovered  a  "  stomach-brush "  to  remove  the 
mucus  from  the  stomach,  "  so  that  at  that  time  there  was  no  beer- 
company  at  which  some  did  not  apply  it  themselves  after  drinking 
heavily,  either  the  same  night  or  on  the  following  morning  after 
having  snored  out  their  intoxication  through  the  open  mouth,  if 
they  were  distressed  with  the  thick  phlegm  in  the  throat."  f  In  the 
latter  half  of  the  previous  century  John  Hunter' introduced  cathe- 

*  Leube.  Die  Magensonde.  Die  Greschichte  ihrer  Entstehung  und  ihrer  Bedeu- 
tung  in  diagnostischer  imd  therapeutischer  Hinsieht.    Erlangen,  1879. 

f  J.  Chr.  Kundman.  Seltenheiten  der  Natur  und  Kunst,  etc.,  1737.  Quoted  by 
Leube. 


THE  STOMACH-TUBE.  5 

ters  into  the  stomach,  but  only  to  inject  irritating  substances  into  it. 
The  Enghsh  surgeon,  F.  Bush,  was  the  first  to  attach  a  pump  to  tlie 
stomach-tube  to  evacuate  the  stomach  in  a  case  of  opium-poisoning ; 
this  discovery  is  attributed  by  others  to  Weiss,  an  instrument-maker. 
The  stomach-siphon  was  first  proposed  by  Arnott*  in  1829,  and 
then  by  Sommerville,  but  passed  into  oblivion.  Kussmaul  f  again 
directed  the  attention  of  the  profession  to  the  stomach-tube  in  his 
publications  in  1867  and  1869,  on  the  treatment  of  dilatation  of  the 
stomach.  Meanwhile  it  had  been  occasionally  recommended,  as  in 
France  by  Blatin,  in  1832,  and  by  Canstatt,;}:  and  was  also  used  here 
and  there.  It  was  always  a  standing,  though  only  privately  uttered, 
claim  of  Prof,  Frerich's  clinic  that  the  pump  had  regularly  been 
used  long  before  Kussmaul's  publications.  But,  as  is  well  known, 
in  disputes  as  to  j^i'iority  in  scientific  matters,  the  time  at  which  the 
subject  in  question  is  made  public  is  decisive,  and  hence  Kussmaul 
deserves  the  credit  of  having  again  called  the  attention  of  the  whole 
medical  profession  in  an  im23ressive  way  to  the  use  and  benefits  of 
the  stomach-tube.  At  the  N^aturforscherversammlung  at  Rostock, 
in  18Y1,  Leube  asserted  the  possibility  of  using  it  for  diagnostic 
purposes,  and,  as  later  developments  proved,  opened  up  an  excellent 
means  of  examination.  Yet  in  his  early  investigations  Leube  as 
well  as  his  predecessors  exclusively  used  a  stiff  tube  or  a  rubber 
tube  with  an  elastic  but  more  or  less  rigid  whalebone  stylet.  This 
procedure  has  many  inconveniences  and  disadvantages.  Instead  of 
this,  I  was  the  first  to  show  that  a  very  soft  tube  without  any  stylet, 
provided  it  had  a  thick  wall  and  a  sufiicient  firmness,  could  be 
easily  introduced  into  the  stomach  in  the  great  majority  of  cases 
requiring  examination.*  As  occurs  so  frequently,  this  was  the  re- 
sult of  chance.  In  1875  a  man  who  had  poisoned  himself  with 
prussic  acid  was  brought  to  the  Frerich  clinic.     The  stomach  had  to 

*  Quoted  by  Alderson,  On  the  Dangers  attending  the  Use  of  the  Stomach-pump. 
Lancet,  January  4,  1879. 

f  Kussmaul,  in  Bericht  liber  die  41.  Versammlung  dentscher  Naturforseher  und 
Aerzte  zu  Franlifurt  a.  Main,  1867;  and  Ueber  die  Behandlung  der  Magenerweite- 
rung  durch  eine  neue  Methode  mittelst  der  Magenpumpe.  Deutsch.  Archiv  filr 
klin.  Medicin,  Bd.  vi,  S.  455. 

I  Canstatt,  in  his  Jahresbericht  for  1841. 

*  Ewald.  A  Ready  Method  of  washing  out  the  Stomach.  Irish  Gazette,  August 
15,  1874,  and  Berlin,  klin.  Wochenschr.,  1875,  No.  1. 


6  DISEASES  OF  THE  STOMACH. 

be  washed  out  at  once.  None  of  tlie  stiff  tubes  wliicli  were  then  in 
use  was  at  hand,  so  I  cut  off  a  piece  of  gas-tubing,  rounded  off  the 
sharp  end,  cut  out  two  eyelets,  oiled  the  tube,  and,  although  the  man 
was  unconscious,  I  easily  succeeded  in  reaching  the  stomach.  A 
similar  procedure  was  published  later  by  Oser.*  It  has  been  suc- 
cessfully tried  on  many  patients,  so  that  now  it  is  quite  universal 
only  to  use  soft,  specially  prepared  tubes  made  of  smooth,  vulcan- 
ized rubber.  They  have  been  used  in  France  since  1880,  and  are 
known  as  tiibes  Faucher.\ 

The  expressions  oesophageal  sound,  oesophageal  tube,  stomach- 
sound,  siphon-sound,  stomach-pump,  stomach-tube,  etc.,  are  indis- 
criminately used  by  writers,  and  not  in  their  true  meaning.  Sounds, 
strictly  speaking,  are  solid  instruments  whose  density  permits  the 
transfer  of  the  sense  of  touch  into  deep  and  inaccessible  places. 
Hollow  instruments  can  only  be  indirectly  used  for  sounding,  if 
their  walls  are  thick  enough,  as,  for  example,  the  use  of  a  catheter 
for  exploring  the  bladder.  The  same  is  true  also  of  the  so-called 
stiff  oesophageal  and  stomach  tubes,  which  may  be  used  to  explore 
the  ossophagus  and  stomach  if  they  are  rigid  enough  and  are 
rounded  off  at  the  end.  But  this  use  is  merely  secondary,  as  their 
true  function  is  indicated  by  their  name  "  tubes  " — i.  e.,  to  allow  the 
passage  of  fluids.  It  is  an  abuse  of  language  to  speak,  as  Leube 
does,  of  a  siphon -sound  {Hehersonde)  instead  of  a  stomach-tube  or 
simply  a  stomach-siphon.  In  the  following  pages  I  shall  speak  of 
all  solid  instruments  as  sounds,  and  of  the  hollow  tubes  with  more 
or  less  rigid  walls  as  stiff  oesophageal  or  stomach  tubes  {Schhmd- 
rohr  or  Magenrohr),  and  of  the  flexible  tubes  (made  of  silk  or  rub- 
])er)  simply  as  stomach-tubes  {Magenschlauch). 

If  the  tube  is  introduced  to  obtain  the  contents  of  the  stomach, 
it  is  naturally  of  primary  importance  that  these  can  easily  enter  and 
leave  the  tube ;  this  is  accomplished  by  having  as  many  and  as 

*  L.  Oser.  Die  mechanische  Behandlung  der  Magen-  und  Darmkrankheiten. 
Wiener  med.  Klinik,  1875  ;  and  Die  Magenausspiilung  mittelst  des  elastischen 
Schlauches.     Wiener  med.  Presse,sl887,  No.  1. 

f  [Faueher's  tubes  are  about  60  inches  long;  the  external  diameter  is  f  to  f  inch; 
the  walls  are  of  such  thickness  that  the  tube  can  be  bent  without  effacing  its 
lumen.  At  one  extremity  is  a  lateral  eye  with  two  orifices ;  to  the  other  extremity 
a  funnel  holding  about  a  pint  is  attached.     Welch, — Tr.] 


THE  STOMACH-TUBE. 


large  openings  as  possible  in  the  lower  portion.  The  ordinary  stiff 
tubes  and  most  of  the  soft  ones  in  general  nse  till  now  have  one  or 
two  openings,  eyelets  or  fenestrse,  as  they  are  called,  near  the  lower 
end ;  this  is  usually  a  blind  end  formed  by  a  closed  tip  made  of  a 
harder  material.  Unless  the  tube  is  very  carefully  cleansed,  all 
kinds  of  organic  substances  may  accumulate  here  and  decompose. 
To  avoid  these  objections  I  have  the  tubes  made  of  different  thick- 
nesses, with  the  lower  end  open,  and,  following 
Schtitz's  suggestion,  have  one  large  fenestra  very 
low  down  and  a  number  of  smaller  openings 
about  the  size  of  a  large  pin's  head  (Fig.  1).  In 
this  way  the  contents  of  the  stomach  may  easily 
enter  the  tube  from  all  sides,  and  can  be  very 
readily  obtained. 

Recently  tubes  made  of  braided  silk  varnished 
over  have  been  introduced ;  they  are  somewhat 
firmer  than  the  soft  rubber  tubes,  but  are  much 
less  rigid  than  the  stiff  ones.  At  my  suggestion 
they  have  been  made  after  the  same  model  as  that 
above. 

It  is  self-evident  that  the  softer  the  instru- 
ment which  is  introduced  into  the  stomach  and 
the  more  rounded  its  edges  are,  the  less  will  be 
the  danger  of  injuring  the  mucous  membrane; 
this  occurs  more  easily  and  has  actually  taken 
place  with  stiff  instruments.  Another  advantage 
of  the  flexible  tubes  is  that,  in  introducing  them, 
as  I  shall  presently  show  you,  it  is  absolutely  un- 
necessary to  introduce  the  finger  into  the  patient's  mouth,  thereby 
sparing  him  the  always  unpleasant  gagging,  and  obviating  the  dan- 
ger of  the  physician  having  his  finger  bitten. 

Under  certain  conditions  it  may  be  impossible  to  pass  a  soft 
instrument  through  the  oesophagus,  even  though  it  be  free  from 
obstruction  ;  then  there  is  also  the  active  resistance  of  the  insane, 
etc.  ;  finally^  we  may  encounter  mechanical  obstructions,  such  as 
unusual  narrowing  of  the  entrance  of  the  oesophagus,  due  to  bony 
protuberances  or  to  a  posterior  displacement  of  the  hyoid  bone  or 


Fig.  1. 


8  DISEASES  OP  THE  STOMACH. 

nervous  spasm  of  tlie  oesophagus.  In  such  cases  it  is  necessary  to 
use  a  more  rigid  tube,  and,  according  to  the  resistance  to  be  over- 
come, we  may  try  either  one  of  the  above-described  silk  tubes,  or 
a  so-called  red  English  tube  made  of  catgut  varnished  over.  I  no 
longer  use  the  black  French  bougies,  which  were  formerly  so  popu- 
lar, as  they  wear  out  too  easily. 

The  majority  of  the  above  instruments  are  T5  ctm.  [29^  inches] 
long,  so  that,  having  been  introduced  into  the  stomach,  only  a 
small  piece  is  left  projecting  between  the  teeth,  as  we  may  usu- 
ally reckon  the  distance  from  the  incisor  teeth  to  the  fundus  ven- 
triculi  as  being  60  to  65  ctm.  [23^  to  25|-  inches].  For  further 
manipulations,  this  small  projecting  piece  may  be  lengthened  before 
or  after  its  introduction  by  attaching  a  small  piece  of  glass  tub- 
iug  with  a  suitable  length  of  rubber  tube  of  the  same  size ;  or,  if 
the  upper  end  of  the  stomach-tube  is  funnel-shaped,  we  may  insert 
a  hard  rubber  stop-cock,  one  side  of  which  has  a  conical  end 
with  a  screw  thread,  while  the  other  side  is  a  smooth  tube  over 
which  soft  rubber  tubing  may  be  slipped.  For  cases  of  dilatation 
of  the  stomach  I  have  had  extra  long  tubes  made  with  a  length  of 
95  ctm.  [3Yi-  inches].* 

All  stifE  instruments  which  are  introduced  into  the  oesophagus 
or  stomach,  as  the  sponge-probang,  bougies,  etc.,  ought  to  be  held 
in  the  right  hand  like  a  pen ;  the  left  index-finger  is  passed  into 
the  patient's  mouth  and  depresses  the  tongue,  the  tip  of  the  finger 
passing  to  the  epiglottis  if  possible  ;  the  tube  is  then  passed  rapidly 
along  the  left  index-finger  to  the  posterior  pharyngeal  wall,  and 
then,  and  not  before,  by  raising  the  right  Avrist  the  point  of  the 
instrument  is  depressed  into  the  oesophagus.  The  more  quickly  and 
boldly  you  manipulate,  the  more  easily  will  the  tube  pass,  and  the 
less  will  the  patient  be  annoyed.  The  danger  of  entering  the  re- 
spiratory passage  is  greatly  exaggerated,  and  the  detailed  accounts 
given  about  it  in  most  text-books  are  quite  superfluous.  Under  nor- 
mal conditions  the  entrance  to  the  larynx  is  at  once  reflexly  closed 
by  the  epiglottis.  But  even  in  paralysis  or  anfesthesia  of  the 
larynx,  and  other  conditions  interfering  with  the  functions  of  the 

*  These  tubes  can  be  obtained  at  Miersch,  Berlin  W.,  Friedrichstrasse  66. 


THE  STOMACH-TUBE.  9 

epiglottis,  only  tlie  greatest  clumsiness  will  cause  the  tube  to  enter 
tlie  larynx  instead  of  tlie  oesophagus.  But  even  if  it  should  occur 
— ^just  as  some  "  doctors "  have  extracted  half  of  the  intestines 
through  a  rupture  of  the  uterus — the  marked  dyspnoea  and  cyanosis 
of  the  patient  and  the  entrance  and  exit  of  air  through  the  tube 
would  at  once  show  that  a  "  mistake  "  had  been  made.  At  the  first 
introduction  of  any  oesophageal  instrument  patients  often  become 
markedly  cyanotic,  because  they  believe  they  can  not  breathe,  and 
therefore  hold  their  breath  spasmodically.  Such  occurrences  must 
not  be  confounded  with  the  above.  Holding  the  breath  may  easily 
be  differentiated  from  a  true  dyspnoea  by  getting  the  patients  to 
breathe  rhythmically  while  we  count  for  them. 

In  introducing  flexible  tubes,  it  is  su23erfluous,  as  Oser  showed, 
to  apply  oil,  vaseline,  or  glycerin  to  the  outside  of  the  instrument. 
It  need  only  be  dipped  in  warm  water,  as  the  abundant  secretion 
of  saliva  by  the  patient  will  lubricate  it  suflSciently.  Let  the  pa- 
tient open  his  mouth,  push  the  tube  on  to  the  posterior  wall  of  the 
pharynx  (the  tube  is  sufficiently  rigid  to  permit  this),  and  then  ask 
the  patient  to  swallow  ;  the  tube  is  grasped  by  the  muscles  of  deg- 
lutition and  passes  without  any  difficulty  into  the  upper  end  of 
the  oesojihagus,  its  passage  through  the  introitus  oesophagi  being 
distinctly  felt ;  then,  by  gently  pushing  the  tube,  it  speedily  reaches 
the  stomach.  At  times  a  slight  resistance  is  felt  at  the  cardia, 
frequently  not.  By  this  method  we  avoid  the  manipulations  in  the 
patient's  mouth  which  are  unpleasant  both  to  the  latter  and  to  the 
physician.  The  procedure  is  much  simplified  and  the  unpleasant- 
ness and  excitement  are  so  much  lessened  that,  among  the  many 
patients  examined  by  me  during  the  past  few  years,  I  have  found 
very  few  cases  in  which  I  could  not  introduce  the  tube.  A¥ith 
a  little  patience  on  the  one  hand,  and  determination  on  the 
other,  we  may  succeed  even  in  nervous  and  anxious  subjects.  The 
patients'  conduct  during  this  procedure  has  afforded  me  an  excel- 
lent test  of  the  strength  of  their  nerves,  and,  as  the  ancients  ex- 
pressed it,  of  their  sanguine  and  lymphatic  temperaments.  In  very 
sensitive  persons,  the  local  sensation  may  be  entirely  abolished  by 
painting  the  posterior  pharyngeal  wall  with  a  10  to  20  23er  cent 
cocaine  solution  a  few  minutes  before  introducing  the  tube,  yet  I 


10  DISEASES  OP  THE  STOMACH. 

have  liardly  ever  found  this  necessary.  But,  even  without  its  use, 
I  may  safely  assert  that  this  procedure  is  much  less  distressing  to 
the  patient  than  a  laryngoscopic  examination  without  cocaine,  as 
the  latter  at  first  sets  up  a  much  greater  irritation. 

Having  introduced  the  tube,  our  next  task  is  to  obtain  the  con- 
tents of  the  stomach.  Here,  also,  the  past  few  years  have  witnessed 
a  great  simplification.  Originally,  the  stomach-pump  was  used ; 
this  instrument  consists  of  a  pump  with  two  tubes — one  below,  the 
other  at  the  side ;  the  fluid  is  drawn  up  through  the  former,  and 
then  by  turning  the  piston,  or  by  some  similar  arrangement  of  the 
valves,  it  is  evacuated  through  the  latter.  Other  even  more  com- 
plicated apparatus  has  been  devised  which,  as  the  proverb  reads, 
make  five  quarters  out  of  a  mile  !  Among  these  may  be  men- 
tioned Jaworski's  stomach-aspirator,  a  contrivance  as  incompre- 
hensible as  it  is  needless,  which  accomplishes  no  more  than  any 
pump  will  do,  and  is  based  upon  the  same  principle,  but  which 
requires  such  an  array  of  bottles  and  glass  tubes  as  from  the  very 
beginning  to  preclude  its  practical  use.  On  the  other  hand,  a 
good  and  simple  method  consists  in  passing  the  stomach-tube  as 
usual,  and  then  attaching  a  piece  of  rubber  tubing,  at  whose  other 
end  a  large  pyriform  rubber  bag  [like  Politzer's  bag]  is  inserted. 
The  bag  is  inserted  after  it  has  been  squeezed  together ;  in  ex- 
panding it  aspirates  the  stomach-contents  so  long  as  subjected  to 
the  ordinary  atmospheric  pressure.  The  bag  may  also  be  used  for 
the  reverse ;  namely,  by  filling  it  with  air  or  water,  attaching  it  to 
the  tube,  and  then  by  squeezing  it  gently  we  may  succeed  in  dis- 
lodging any  pieces  of  food  Avhich  may  obstruct  the  lumen  of  the 
tube,  as  is  recognized  by  the  cessation  of  the  resistance  caused  by 
the  plug.  Boas  *  has  recently  suggested  the  use  of  a  rubber  bulb 
with  a  short  rubber  tube  on  either  side  ;  one  of  these  is  attached  to 
the  stomach-tube  by  means  of  a  small  piece  of  glass  tubing ;  on 
the  other  is  a  pinch-cock  (Fig.  2).  A  vacuum  is  obtained  by  com- 
pressing the  bulb  while  the  cock  is  open ;  when  the  latter  is  closed 
the  contents  of  the  stomach  will  be  sucked  up  into  the  bulb.  The 
cock  is  now  opened  while  the  tube  on  the  other  side  of  the  bulb 


*  I.  Boas.    Allgemeine  Diagnostik  und  Therapie  der  Magenkrankheiten.    Leip- 
zig, 1890.    S.  106. 


THE   STOMACH-TUBE. 


11 


is  compressed  ;  by  squeezing  the  bulb,  whatever  has  been  aspirated 
may  be  expelled  into  a  vessel  held  under  the  free  end  of  the  tube 
with  the  cock. 

[Einhorn  *  has  devised  his  stomach-hticket  for  obtaining  small 
quantities  of  stomach-contents.     This  consists  of  a  small,  hollow, 


silver  capsule,  with  an  opening  at  its  upper  end,  A  long  silk 
thread  is  attached  to  a  thin  bar,  which  is  stretched  across  this  open- 
ing ;  the  thread  carries  a  knot  at  40  ctm.  (1 6  inches)  to  indicate 
when  the  bucket  is  in  the  stomach.  The  patient  is  directed  to 
open  his  mouth  widely,  the  bucket  is  placed  on  the  root  of  the 
tongue,  and  with  a  single  swallow  it  passes  into  the  stomach.  It 
is  removed  by  traction  on  the  thread.  N^ot  infrequently  the  oj)en- 
ing  is  plugged  by  mucus  ;  this  may  be  prevented  by  placing  a 
thin  disk  of  gelatin  over  it.  Sometimes  only  mucus  is  brought 
up ;  the  bucket  must  then  be  passed  again.  This  method  is 
not  applicable  where  large  quantities  of  stomach-contents  are  re- 
quired.] 

But  usually  all  these  manipulations  are  unnecessary.  Some  time 
ago  Dr.  Boas  and  myself  showed  that  the  stomach-contents  could  be 
obtained  at  any  time  by  means  of  the  abdominal  pressure,  since  the 
straining  of  the  patient  suffices  to  drive  the  contents  of  the  stomach 
into  the  tube,  provided  they  are  sufficiently  fluid,  so  that  the  lumen 
of  the  tube  is  not  occluded. f     Since  then  the  method  has  been  tried 


*  [Einhorn,  New  York  Medical  Record,  vol.  xxxviii,  p.  63.  Its  use  is  condemned 
by  Boas,  loc.  cit.,  2d  ed.,  p.  112. — Tr.] 

f  Ewald  und  Boas.  Beitrage  zur  Physiologic  mid  Pathologic  der  Verdauung. 
Virchow's  Archiv,  Bd.  ci,  S.  325-375;  ib.,"Bd.  civ,  S.  271-305. 


12  DISEASES  OP  THE  STOMACH. 

by  many  others  "  witli  excellent  results,"  and  has  been  designated 
the  Ewald  Expression  Method  {die  Ewald''sche  Expressionsmethode). 
It  is  true  that  some  one  may  now  and  then  have  observed  that  the 
stomach-contents  were  forced  from  the  tube  during  acts  of  coughing, 
etc. ;  yet  Boas  and  myself  may  claim  the  credit  of  having  system- 
atized the  method,  and,  by  its  means,  of  having  greatly  simplified 
the  technique.  I  think  that  this  claim  is  the  more  justifiable, 
since  by  the  combination  of  the  flexible  tube  and  "expression" 
these  examinations  for  the  first  time  fulfilled  the  requirements  "de- 
manded of  every  good  method,  namely,  to  operate  cito,  t^ito,  and, 
as  far  as  possible,  jucunde.  This  is  surely  not  unimportant,  but 
even  fundamental. 

This  method  should,  however,  always  be  avoided  in  cases  where 
there  is  danger  of  rupture  of  an  aneurism,  brittle  blood-vessels,  etc., 
on  account  of  the  somewhat  violent  contraction  of  the  muscles  of 
the  abdomen  which  it  entails.  But  such  cases,  like  the  one  which  I 
communicated  to  the  Berlin  Medical  Society  (reported  in  the  Berl. 
klin.  Wochenschrift,  July  28,  1890),  are  the  exce^jtion,  and  may  be 
avoided  by  the  use  of  the  proper  precautions,  or  must  be  looked 
u23on  as  the  unfortunate  and  inevitable  complications  which  may 
arise  in  the  routine  application  of  any  method  in  medical  practice. 
It  is  a  safe  rule  to  avoid  this  method  in  any  case  in  which  force 
must  be  used  for  expression,  and  to  have  recourse  to  aspiration  as 
soon  as  the  outflow  ceases  to  be  smooth  and  easy, 

Eecently  C.  Albutt  *  wrote  as  follows  concerning  washing  out 
of  the  stomach :  "  This  troublesome  and  disgusting  performance 
offends  the  more  refined  class  of  patients,  and  in  dealing  with  them 
the  physician  is  too  soon  persuaded  to  lay  it  aside,  or  altogether  to 
forbear  the  use  of  the  stomach-pump."  If  he  will  try  the  method 
just  described,  his  results  will  be  more  encouraging.  I  could  easily 
mention  the  names  of  very  distinguished  people  who  willingly  al- 
lowed the  introduction  of  the  tube  and  the  wasliing  out  of  the 
stomach ;  and  I  consider  the  diagnostic  importance  of  the  "  expres- 
sion method  "  to  be  so  great  and  the  safety  to  be  so  absolute,  a  very 

*  C.  Albiitt.  On  Simple  Dilatation  of  the  Stomach,  or  Gastroectasis.  Lancet, 
November  5,  1887. 


THE  STOMACH-TUBE. 


13 


few  eases  excej^ted,  that  I  would  reproach  myself  had  I  neglected 
to  resort  to  it  in  any  doubtful  case. 

Epstein  *  has  even  applied  the  treatment  with  the  stomach-tube 
very  successfully  in  very  small  children,  even  in  infants ;  the  tube 
was,  of  course,  of  a  corresponding  size — i.  e.,  a  Nelaton  catheter, 
ISTos.  8,  9,  and  10  (French).  Leo  f  has  used  this  method  for  the  sys- 
tematic study  of  the  functions  of  the  stomach  in  suckling  infants. 

It  soijietimes  happens  that,  although  the  stomach  is  full,  none  of 
its  contents  can  be  obtained  by  any  of  these  methods.  This  may  be 
due  to  an  occlusion  of  the  fenestras  of  the  tube,  either  by  a  prolapse 
of  the  mucous  membrane,  or  they  may  be  ]3lugged — both  of  these 
occur  very  rarely 
with  my  method  ;  or 
the  tube  may  have 
been  introduced  too 
far  and  has  curled 
around  along  the 
greater  curvature, 
and  thus  the  end  is 
above  the  level  of 
the  contents  of  the 
stomach,  as  is  shown 
in  Fig.  3.  This  is 
easily  remedied  by 
withdrawing  the 
tube  a  little  (Fig.  3). 

In  rare  cases  it 
may  also  happen  that  at  a  time  after  the  test-breakfast  when  the 
stomach  is  usually  full,  the  organ  is  found  empty,  and  hence  noth- 
ing can  be  expressed.  In  such  cases  the  transfer  of  the  ingesta  into 
the  intestines  is  unusually  rapid — a  condition  which  will  be  referred 
to  in  the  discussion  of  the  gastric  neuroses. 

1  shall  now  demonstrate  to  you  on  a  patient  how  easily  this 


Fig.  3. 


*  Epstein.  Ueber  Magenausspiilung  bei  Sauglingen.  Archiv  fiir  Kinderheil- 
kunde,  1883,  Bd.  iv,  S.  325. 

f  Leo.  Ueber  die  Function  des  normalen  iind  kranken  Magens,  etc.,  im  Saug- 
lingsalter,     Berl.  klin.  Wochenschrift,  1888,  No.  49. 


14  DISEASES  OF  THE  STOMACH. 

method  of  expression,  as  I  have  called  it,  is  carried  out.  (Demon- 
stration.) Although  very  rapidly  done  on  this  patient,  yet  I  must 
not  neglect  to  tell  you  that  in  some  cases  it  is  not  successful.  Thus 
this  may  happen  where  the  abdominal  walls  are  so  relaxed  that  tlieir 
jDressure  can  not  be  brought  into  play ;  then  there  are  also  some 
persons  who  have  so  little  control  over  their  muscles  that  they  can 
not  bear  down  when  they  are  told  to  do  so.  Hence  this  method  of 
expression  may  not  be  successful,  or  at  least  not  till  after  several 
attempts ;  yet,  taken  all  together,  this  occurs  in  scarcely  five  per 
cent  of  the  cases. 

Are  the  passage  of  the  tube  and  the  washing  out  of  the  stomach, 
as  thus  described,  dangerous?  You  know  that  when  the  stiff  tubes 
and  the  pump  were  exclusively  used,  numerous  cases  were  reported 
where  pieces  of  the  mucous  membrane  were  torn  off,  as  by  Wies- 
ner,*  von  Ziemssen,f  Leube,  ^  Schliep,  *  and  others ;  yet  they  were 
followed  by  no  evil  consequences,  at  least  so  far  as  haemorrhages 
and  the  formation  of  gastric  ulcers  were  concerned.  This  may  be 
due  to  the  strong  contraction  of  the  walls  of  the  stomach,  which  at 
once  closed  any  bleeding  vessels  and  apjDroximated  the  edges  of  the 
denuded  areas. 

The  possibility  of  such  an  occurrence,  and  in  fact  of  any  severe 
lesion  of  the  mucous  membrane,  is  reduced  to  a  minimum  by  the 
use  of  the  flexible  tube ;  and  in  this  way  there  has  been  removed  a 
serious  objection  which  prevailed  up  to  quite  recently  against  the 
internal  exploration  of  the  stomach  in  certain  conditions,  such  as 
cancer  and  ulcer,  where  bleeding  occurs  easily.  A  very  unpleasant 
complication  is  regurgitation  of  food  alongside  of  the  tube;  this 
may  even  lead  to  suffocation,  aspiration-pneumonia  {Schkichpneu- 
monie),  etc.  ||  This  may  be  guarded  against  by  the  local  or  internal 
use  of  cocaine  in  very  nervous  patients.     The  choking  sensation  is 

*  Wiesner.     Ueber  die  Behandlung  der  Ectasie  mittelst  der  Magenpumpe.    Ber- 
liner klin.  Wochensehr.,  1870,  No.  1,  S.  3. 

f  V.  Ziemssen.    Zur  Technik  der  Loealbehandlung  des  Magens.    Deutsch.  Ar- 
chiv  flir  klin.  Med..  Bd.  x,  S.  66. 

X  Leube.     Die  Magensonde.     Erlangen,  1879,  S.  25. 

*  Schliep.     On  the  Stomach-pump  in  the  Treatment  of  Chronic  Gastric  Catarrh 
and  Dilatation.     Lancet,  December  14,  1872. 

II  Emminghaus.  Einiges  liber  Diagnostik  und  Therapie  mit  der  Schlundsonde. 
Deutsch.  Archiv  fiir  klin.  Med.,  Bd.  xi,  S.  304. 


THE  STOMACH-TUBE.  15 

much  less  marked  after  the  test-breakfast  {Prohefruhstilch — vide 
infrci),  for  its  intensity  is  manifestly  regulated  by  the  amount  of 
the  ingesta,  and  the  masses  raised  are  smaller  as  well  as  less  offen- 
sive. It  ceases,  as  a  rule,  after  pouring  some  water  into  the  stom- 
ach, since  the  irritation  of  the  mucous  membrane  by  the  tube  is 
thus  removed. 

I  have  never  met  with  any  serious  accidents,  neither  large  hgem- 
orrhages  nor  any  other  mishap ;  and  can  agree  with  Leube's  state- 
ment that,  "  taken  all  in  all,  the  passage  of  the  tube  into  the  stom- 
ach is  to  be  considered  an  operation  without  risk  "  ;  *  but  I  would 
modify  it  by  substituting  for  "  taken  all  in  all "  the  expression  "  if 
the  necessary  care  be  taken." 

It  is  self-evident  that  in  the  examination  of  the  contents  of  the 
stomach  a  method  which  is  as  uniform  as  possible  should  be  fol- 
lowed. The  activity  of  the  gastric  secretion  depends,  mutatis 
mutandis,  upon  the  food  eaten.  The  quantity  is  abundant  if  a 
good  opportunity  is  offered  for  free  secretion.  An  abundance  of 
food  calls  forth  a  greater  activity  of  the  glands  than  a  scanty  diet, 
till  the  food  present  is  saturated  with  the  secreted  juice.  There- 
fore, different  results  will  be  obtained  if  the  examinations  are  made 
after  varying  intervals  and  after  different  kinds  of  food.  The 
neglect  of  this  point  was  the  cause  of  the  great  discrepancies  be- 
tween the  various  writers  up  to  a  short  time  ago  ;  hence  it  is  abso- 
lutely indispensable  that  the  interval  after  the  meal  and  the  diet 
should  always  be  the  same,  if  the  results  are  to  be  of  any  value  for 
comparison. 

The  question  naturally  arises.  What  is  the  normal  course  of  the 
secretion  in  human  beings  ?  A  continuous  series  of  experiments 
on  the  successive  phases  of  digestion  in  animals,  as  well  as  in  hu- 
man beings,  had  never  been  made  till  Dr.  Boas  and  myself  made 
ours  on  the  latter  some  years  ago.  First  of  all  we  corroborated  the 
results  of  Tiedeman  and  Gmelin  (1826)  and  others  that  there  is 
normally  no  gastric  juice  in  the  stomach  when  fasting  ;  that  some 
kind  of  irritation  of  the  gastric  mucous  membrane  is  necessary  to 
produce  the  secretion,  either  by  the  simple  introduction  of  a  sound 

*  Leube,  loc.  cit.,  p.  40. 


16  DISEASES  OP  THE  STOMACH. 

or  tube,  as  in  very  nervous  persons,  or  by  giving  some  water,  pep- 
per, etc.  Thus,  for  example,  Edinger  *  found  that  in  13  out  of  15 
cases  there  was  no  trace  of  hydrochloric  acid,  and  in  the  other  two  a 
"  by  no  means  positive "  trace  of  it.  He  used  the  old  method  of 
Spallanzani,  in  which  the  subjects  swallowed  pieces  of  sponge  com- 
pressed to  the  size  of  a  pill,  and  attached  to  a  silk  thread.  Con- 
cerning this  it  must  be  stated  that,  in  persons  who  have  not  eaten 
for  an  unusually  long  time,  the  introduction  of  the  tube  may  not 
cause  a  secretion  of  gastric  juice,  but  instead  a  regurgitation  of  bile 
and  other  contents  of  the  duodenum.  This  is  not  a  normal  occur- 
rence, as  will  easily  be  perceived  from  the  standards  to  be  given 
later  on.  Schreiberf  and  Rosin,:};  after  very  thorough  experiments, 
have  recently  claimed  that  the  secretion  in  the  stomach  is  continuous. 
At  all  events,  it  was  found  that  in  14  out  of  15  persons  examined  for 
this  purpose  from  2  to  50  c.  c.  [f  3  ss.  to  3  jss.]  of  a  fluid  containing 
hydrochloric  acid  could  be  expressed  from  the  stomach  Avhen  free 
from  food ;  the  fluid  was  usually  clear  as  water,  with  very  little 
potash  and  no  remnants  of  food ;  in  a  few  cases  it  was  colored 
green  or  yellow.  Likewise,  in  10  out  of  11  persons  who  had 
fasted  seven  hours,  some  of  them  even  the  greater  part  of  the  day, 
a  fluid  containing  hydrochloric  acid  could  always  be  obtained  by 
expression,  repeated  at  a  few  hours'  interval.  Schreiber  thinks 
he  can  exclude  the  possibility  of  this  secretion  having  been  pro- 
duced at  the  time  of  the  introduction  of  the  sound  or  tube  ;  yet  he 
does  not  state  whether  it  is  the  product  of  the  entire  period  of 
fasting  (i.  e.,  for  instance,  that  secreted  continuously  during  the 
whole  night),  nor  does  he  make  it  clear  when  the  secretion  begins. 
Leo*  and  Kinnicutt  j,  who  found  hydrochloric  acid,  "  almost  with- 
out exception,"  in  the  stomachs  of  fasting  suckling  infants,  consider 

*  Edinger.  Zur  Physiologie  unci  Pathol ogie  des  Magens.  Deutsch.  Archiv  flir 
klin.  Med.,  Bd.  xxix,  1881. 

f  J.  Schreiber.  Die  spontane  Saftabscheidung  des  Magens  ira  Ntichternen  imd 
die  Saftsecretion  des  Magens  im  Fasten.  Arch,  fiir  experim.  Pathologic  nnd 
Pharmakologie.     Bd.  xxiv,  S.  365. 

X  H.  Rosin.  Ueber  das  Secret  des  ntichternen  Magens.  Deutsche  med.  "Woch- 
ensehr.,  1887,  No.  47. 

*  Leo,  loc.  cit. 

II  Kinnicutt.  Diagnosis  of  Diseases  of  the  Stomach.  Transactions  of  the  Asso- 
ciation of  American  Physicians,  vol.  v,  p.  216. 


THE  TEST-BREAKFAST.  17 

it  a  residue  of  the  previous  process  of  digestion  ;  while  Rosen- 
heim *  agrees  perfectly  with  my  results,  and  states  that  normally 
the  stomach  contains  only  traces  of  hydrochloric  acid  (never  over 
0-Ott  per  thousand  f).  I  can  not  admit  that  Schreiber's  experiments 
are  convincing,  and  that  the  glands  of  the  stomach,  unlike  all  other 
secreting  glands,  are  active  without  any  specific  stimulation,  some- 
what like  a  steam-engine  "going  dead  slow."  I  still  consider  that 
the  simple  act  of  introducing  the  tube  in  most  persons  who  have  not 
become  accustomed  to  it  by  long  practice  causes  a  reflex  fy^om  the 
mouth  downward^  and  this  reflex  action  will  suffice  to  call  forth 
a  more  or  less  marked  secretion  of  gastric  juice.  Furthermore, 
this  will  occur  more  readily  the  longer  the  person  has  remained 
hungry  beyond  the  usual  time  of  eating,  exactly  as  happens  in 
the  salivary  glands  of  dogs,  w^hich,  when  a  piece  of  meat  is  held 
before  them,  secrete  the  more  abundantly  the  longer  they  have  been 
starved.  Proof  of  this  was  afforded  me  in  five  patients  who  were 
accustomed  to  the  passage  of  the  instrument.  I  passed  the  tube 
while  the  patients  were  in  bed  a  short  time  before  breakfast,  but 
I  obtained  only  small  quantities  of  clear  mucus,  at  times  of  a  yellow 
color.  This  mucus,  although  having  a  feeble  acid  reaction  several 
times,  never  gave  a  reaction  with  the  tropaeolin  or  the  phloroglucin- 
vanillin  tests.  It  may  be  objected  that  these  were  patients  with 
diseased  stomachs  ;  yet  they  always  secreted  gastric  juice  w^ith  hy- 
drochloric acid  after  taking  food.  At  all  events,  the  contradictory 
results  given  by  the  above  writers  show  that  idiosyncrasy  causes 
some  to  react  more  easily  than  others,  and,  as  we  shall  see  later  on, 
this  may  under  certain  conditions  even  lead  to  a  pathological  in- 
crease of  the  secretion. 

The  food  should  be  as  simple  as  possible  ;  it  is  well  typified 
in  the  so-called  test-hreakfast  {ProbefriihstilcTc).  On  an  empty 
stomach  the  patients  take  an  ordinary  dry  roll  and  a  definite  quan- 
tity— "I  litre  [about  f  pint] — of  fluid,  of  either  simply  warm  water  or 

*  T.  Rosenheim.  Ueber  die  Sauren  des  gesunden  und  kranken  Magens  bei 
Einfiihrung  von  Kohlenhydraten.     Virchow's  Archv,  Bd.  cxi,  S.  419. 

f  [0-04  per  thousand,  or  0-04  pro  mille,  as  it  is  usually  expressed  in  German, 
equals  f  g^^^.  This  is  a  very  convenient  way  of  expressing  these  high  fractions  in 
the  decimal  system.  They  can  easily  be  converted  back  into  fractions  by  remem- 
bering that  1  pro  mille  (or  O'l  per  cent)  equals  xwu- — Tr.] 


18  DISEASES  OP  THE  STOMACH. 

weak  tea  [without  milk  or  sugar].  (Tea  sometimes  lias  a  feeble  acid 
reaction,  depending  on  the  province  from  which  the  tea-leaves  come.) 
According  to  Konig's  analysis,  such  rolls  contain  Y  per  cent  nitrogen, 
0'5  per  cent  fat,  4  per  cent  sugar,  and  52*5  per  cent  non-nitro- 
genous extractive  substances,  to  which  1  per  cent  ash  must  be 
added.  The  roll  is  thus  a  mixture  of  the  various  nutritious  ingre- 
dients, and  is  made  up  here  [Berlin]  of  a  tolerably  uniform  weight, 
about  35  grammes  [540  grains].  The  test-breakfast  thus  includes 
albuminoids,  sugar,  starches,  non-nitrogenous  extractives,  and  also 
salts  ;  the  tea  belongs  to  that  group  of  foods  which  are  of  con- 
siderable importance  to  the  gastric  secretion.  Klemperer  recom- 
mends substituting  -J  litre  [a  pint]  of  milk  instead  of  the  tea,  in 
order  to  subject  the  stomach  to  a  severer  test.  As  yet  I  have  not 
been  able  to  obtain  any  special  advantage  from  this.  By  means 
of  this  breakfast  we  can  offer  the  stomach  all  the  ingredients 
which  are  usually  taken,  with  the  great  advantage  that  they  are 
liquefied  in  a  relatively  short  time,  or  at  least  they  are  softened 
sufficiently  to  permit  their  passage  through  the  tube  ;  while  if  solid 
food  like  meat  is  given  the  openings  in  the  tube  are  very  easily 
plugged. 

This  also  explains  why  many  can  not  dispense  with  the  stom- 
ach-pump, which  naturally  gives  greater  suction-power.  My  method 
has  the  additional  advantage  of  great  cleanliness.  Even  should 
the  patient  vomit,  as  occurs  occasionally  in  a  very  few  cases,  the 
vomit  does  not  consist  of  fatty,  offensive,  and  viscous  masses,  as 
when  a  large  meal  is  taken,  but  only  of  comparatively  clean  morsels 
of  bread.  These  are  the  advantages  of  the  method.  On  the  other 
hand,  it  must  not  be  forgotten  that  such  a  moderate  meal  makes  a 
a  very  slight  demand  on  the  action  of  the  viscus,  and  a  stomach 
which  may  prove  capable  of  digesting  this  moderate  meal  may  not 
secrete  enough  for  a  more  complicated  diet.  This  objection  ap- 
plies with  even  greater  force  to  the  one-sided  administration  of 
small  quantities  of  albumen  only  (the  whites  of  one  or  two  hard- 
boiled  eggs),  as  proposed  by  Jaworski.  It  is  for  this  reason  that  I 
deny  the  value  of  such  a  meal  to  test  all  the  digestive  functions 
of  the  stomach.  If  we  have  given  the  trial-breakfast,  and  still 
desire  to  apply  severer  tests,  nothing  forbids  the  use  of  another 


THE  TEST-DINNER.  19 

kind   of   food  to   ascertain   whether    the   latter   is    also    properly- 
digested.* 

Larger  meals,  like  the  test-dinner  {Pr6beinittaghrod\  to  be 
taken  at  noon,  have  been  employed  by  other  observers  (Leube, 
Riegel).  The  test-dinner  consists  of  an  ordinary  [German]  midday 
meal  of  bouillon,  barley  or  Hour  soup,  a  moderate  piece  of  meat, 
and  some  bread.  ISTaturally  a  uniform  quantity  should  be  given 
at  these  meals — about  400  grammes  [about  13  il.  oz.]  of  soup,  60 
grammes  [2  oz.]  scraped  beef,  and  50  grammes  [If  oz.]  wheat 
bread.  This  is  not  so  easily  carried  out,  and  the  same  interval 
should  also  be  allowed  to  elapse  before  the  examination.  Further- 
more, the  large  quantity  of  acid  salts  taken  in  the  food,  as  shown  by 
Einhorn,f  may  cause  quite  a  serious  error  if  the  absolute  quantity 
of  HCl  is  unknown  and  the  total  acidity  is  computed  as  IICl.  In 
my  method  digestion  is  at  its  height  within  one  hour  after  eating, 
and  all  the  constituents  can  be  demonstrated ;  but  in  the  large 
meals  either  no  digestion  at  all  or  very  little  will  have  taken  place 
in  that  time.  You  must  wait  four  to  six  hours,  according  to  the 
state  of  the  food,  or  at  times  upon  the  condition  of  the  organ,  till 
you  can  obtain  all  the  ingredients  properly  digested ;  and  as  the 
fluid  portions  of  the  food  are  absorbed  much  more  rapidly  than  the 
solids,  the  contents  of  the  stomach  after  a  time  become  more  and 
more  like  mush,  so  that  it  may  easily  hapj)en  that  at  this  time  a 
sufficient  quantity  of  the  stotnach-contents  can  not  be  obtained. 
The  longer  period  of  waiting  is  of  less  importance,  since,  after  all, 
we  are  looking  for  comparative  results ;  yet  so  great  have  been  the 
advantages  of  the  test-breakfast  that  I  have  not  discovered  any  rea- 
son for  seeking  further,  especially  as  numerous  trials — even  in  car- 
cinoma of  the  stomach,  let  it  be  well  noted — have  shown  that  the 
same  residts  are  obtained  with  it  as  with  the  more  complicated 
meals.  It  is  .especially  convenient  where  large  numbers  of  exam- 
inations must  be  made,  and  hardly  anything  else  could  be  used  in 

*  [As  the  result  of  eight  examinations  on  healthy  subjects,  Boas  says  that  one 
hour  after  taking  a  roll  and  300  c.  c.  [f  1  x]  of  water,  about  40  e.  c.  [f  3  1^]  should  be 
obtained  by  expression  ;  the  amount  may  vary  15  c.  c.  [f  §  ss.]  either  way  ;  otherwise 
the  result  is  pathological.     Boas,  loc.  cit.,  p.  115. — Tr.] 

f  Einhorn.  Probefriihstiick  oder  Probemittagbrod  ?  Berl.  klin,  Wochenschrift, 
1888,  No.  33. 

3 


20  DISEASES  OP  THE  STOMACH. 

consultation  practice,  where  tlie  patient's  general  condition  is  deter- 
mined on  one  day  and  early  on  the  following  morning  he  may 
come  for  the  examination  of  the  stomach,  and  thus  the  inconven- 
iences of  the  procedure  are  reduced  to  a  minimum. 

If  the  fluid  obtained  by  expression  after  the  test-breakfast  is 
filtered,  the  filtrate  is  a  clear,  at  times  yellowish  or  yellowish-brown, 
watery  fluid,  like  the  specimen  which  I  now  show  you,  which  was 
obtained  by  expression  this  morning. 

You  know  that  the  stomach  during  digestion  normally  has  acid 
contents,  the  acidity  being  due  to  hydrochloric  acid,  and  the  inten- 
sity of  which  depends  upon  the  functional  activity  of  the  organ 
and  the  stage  of  the  digestive  j^rocess.  But  the  nature  of  the  acid 
which  imparts  this  acidity  changes  also.  It  is  therefore  necessary 
to  determine  first  whether  the  stomach-contents  are  acid,  then  how 
acid  they  are,  andfi/nally  the  nature  of  the  acid  which  produces  the 
acidity.  During  the  normal  digestion  of  the  test-breakfast  the  fol- 
lowing three  stages  may  be  observed,  provided  the  reagents  to  he 
presently  described  are  employed.  As  early  as  ten  to  fifteen  min- 
utes after  eating,  the  stomach -contents  obtained  are  acid ;  the  acid- 
ity depends  either  upon  acid  salts  or  free  acid,  or  both.  Exami- 
nation of  the  free  acid  with  our  usual  reagents  shows  it  to  be 
lactic  acid.  Up  to  thirty  to  forty-five  minutes  the  lactic  acid  pre- 
dominates, while  the  color-tests  for  hydrochloric  acid  are  negative. 
Then  comes  a  stao;e  in  which  distinct  traces  of  HCl  can  be  demon- 
strated,  coexisting  with  the  lactic  acid.  Finally,  the  latter  disappears 
entirely,  so  that  normally  after  the  first  hour  only  HCl  can  be 
found.  Of  course,  this  must  not  be  understood  as  meaning  that  it 
is  then  only  that  its  secretion  begins.  On  the  contrary,  it  probably 
begins  at  once  after  the  entrance  of  food  into  the  stomach  ;  but  at 
first  it  can  not  be  demonstrated  with  the  customary  reagents,  because 
a  portion  of  it  is  in  combination,  and  also  on  account  of  the  pres- 
ence of  acid  salts  which  interfere  with  tlie  delicacy  of  the  usual 
reagents.  The  amount  of  free  HCl  rises  during  the  course  of  di- 
gestion, and  reaches  its  maximum,  which  generally  seems  to  be 
higher  after  an  abundant  meal  than  after  a  light  one  (2  to  3'3  per 
thousand  [^^o"  '^^  wo"]  against  1*5  to  2  per  thousand  [-g^  to  -g^]). 
This  difference  in  the  quantity  of  tlie  secretion  bears  no  relation  to 


THE   THREE   STAGES   OP   ACIDITY.  21 

differences  in  its  reaction  to  disturbing  influences ;  in  other  words, 
disturbances  of  digestion,  as  I  have  already  said,  occur  in  the  one 
case  as  well  as  in  the  other,  because  they  dejDend  n(»t  on  absolute 
but  on  relative  values — of  course  witliin  certain  limits,  above  or 
below  which  they  must  not  go. 

The  above  results  are  typical,  and  can  be  demonstrated  with  the 
processes  soon  to  be  described.  The  clinical  and  practical  impor- 
tance of  these  three  stages  of  acidity  lies  in  the  fact  that  changes  in 
them  enable  us  to  recognize  pathological  conditions.  The  validity 
of  this  will  not  be  affected  by  the  fact  that  Calm  and  von  Mering,* 
Ritter  and  Hirsch,f  and  Rosenheim, ;};  with  the  aid  of  complicated 
methods  of  detecting  traces  of  lactic  acid,  succeeded  in  demonstrat- 
ing this  acid  in  the  later  stages  of  digestion.  At  all  events,  it  is 
possible,  as  I  myself  have  ascertained  in  several  cases,  to  find  small 
traces  of  lactic  acid  at  a  time — at  the  end  of  the  first  hour,  for  in- 
stance— when  for  all  practical  purposes  the  tests  to  be  described 
later  (page  33)  no  longer  give  a  positive  result.  But  in  this  lack  of 
sensitiveness  lies  the  value  of  this  test.  For  we  have  no  method  by 
which  an  excess  of  lactic  acid  could  be  quickly  estimated ;  hence  the 
value  of  a  reaction  which,  as  in  the  case  here,  only  becomes  evident 
when  there  is  a  pathological  increase  of  lactic  acid  in  the  stage  of 
digestion  under  discussion.  I  am  therefore  justified  in  maintaining 
that  the  value  of  this  division  of  stomach  digestion  into  three  stages, 
as  proposed  by  Boas  and  myself,  is  not  diminished  by  the  above- 
mentioned  results,  even  should  their  occurrence  be  constant. 

The  acid  reaction  of  the  stomach-contents  may,  under  certain 
conditions,  depend  throughout  the  entire  process  of  digestion,  not 
upon  free  acids  but  upon  the  acid  salts  of  the  iugesta,  especially  the 
acid  phosphates.  Usually  these  salts  play  an  insignificant  part  as 
compared  to  the  free  HCl,  but  under  pathological  conditions  they 
may  become  important. 

Therefore  the  simple  fact  that  the  chyme  reacts  acid  to  litmus 


*  Cahn  und  v.  Mering.  Ueber  die  Sauren  des  gesundeii  und  kranken  Magens. 
Deutsch.  Archiv  1  klin.  Med.,  Bd.  xxxix,  Hefte  3  u.  4. 

f  Loc.  cit.,  p.  434. 

X  Rosenheim.  Ueber  Magensaare  bei  Amylaceenkost.  Centralblatt  fiir  d.  medi- 
cin.  Wissensch.,  1887,  No.  46 ;  and  Virchow's  Archiv,  Bd.  exi,  S.  414. 


23  DISEASES   OF  THE  STOMACH. 

does  not  sliow  wliether  the  acidity  is  due  to  free  HCl  or  acid  salts. 
Under  all  conditions  it  is  important  to  ascertain  liow  acid  the  stom- 
ach-contents are — i.  e.,  to  test  the  acidity  with  volumetric  solutions 
and  the  burette  (titration). 

Testing  Total  Acidity. — Titration*  is  most  conveniently  per- 
formed with  a  deci-normal  solution  of  caustic  soda,  the  end-reac- 
tion being  determined  with  litmus-paper  or  phenol-phthallein.  The 
latter  is  not  as  accurate  as  the  so-called  TujyfelnieiJiode — i.  e.,  the 
alternate  testing  with  red  or  blue  litmus-paper — but  it  is  much  more 
convenient  and  rapid,  while  it  is  sufficiently  accurate  for  general 
practice.  Should  the  reaction  of  the  stomach-contents  be  alkaline, 
the  degree  of  alkalinity  may  be  determined  with  a  deci-normal  acid 
solution.  Phenol-phthallein  is  a  buif-colored  powder,  freely  soluble 
in  alcohol,  making  a  slightly  opalescent  solution,  which  remains 
colorless  in  acid  or  neutral  solutions,  but  assumes  a  carmine  color  in 
alkaline  solutions.  The  procedure  is  simple :  a  Mohr's  burette  is 
filled  with  the  deci-normal  solution  of  caustic  soda ;  5  or  10  c.  c. 
of  the  filtered  stomach-contents  are  poured  into  a  small  glass 
];>eaker,  and  one  or  two  drops  of  the  alcoholic  solution  of  phenol- 
phthallein  are  added.  The  solution  in  the  burette  is  very  grad- 
ually added  till  the  red  color  which  appears  in  the  contents  of 
the  beaker  no  longer  disappears  on  shaking,  but  remains  jjerma- 
nently.  A  slight  turbidity  or  yellowish  color  of  the  stomach-con- 
tents does  not  interfere  with  the  delicacy  of  the  reaction ;  it  is 
also  to  be  noted  that  the  addition  of  the  phenol-phthallein  gives 
a  slightly  milky  appearance  to   many   stomach-contents.f     In  the 

*  [The  description  of  the  technique  of  titration  and  other  strictly  chemical  pro- 
cedures lies  beyond  the  province  of  this  work.  Those  who  desire  further  informa- 
tion than  is  given  in  the  text  will  find  these  methods  fully  described  in  the  Hand- 
book of  Volumetric  Analysis,  by  Edward  Hart ;  New  York,  John  Wiley  &  Sons. 
In  all  these  volumetric  methods  the  metric  system  is  obviously  alone  employed. 
— Tr.] 

f  Where  titrations  are  not  made  daily,  Kleinert's  burette  will  be  found  very 
convenient.  This  burette  differs  from  the  ordinary  form  with  glass  stop-cock  in 
liaving  the  latter  at  the  upper  end  above  the  zero-mark  of  the  scale,  while  the 
lower  end  is  somewhat  drawn  out,  and  is  ground,  to  permit  its  being  closed  with  a 
glass  cover.  The  burette  is  filled  by  dipping  the  lower  end  into  the  standard  solu- 
tion to  be  used  and  sucking  at  the  upper  end  while  the  stop-cock  is  open.  By  clos- 
ing the  latter  the  atmospheric  pressure  will  keep  the  column  of  fluid  in  the  burette. 
To  titrate,  we  simply  turn  the  stop-coek  above  instead  of  below,  as  usual.    After 


TESTING  TOTAL  ACIDITY.  23 

specimen  we  are  now  examining  6"1  c.  c.  of  tlie  deci-normal  solu- 
tion were  added  to  the  10  c.  c.  of  stomach-contents.  As  a  rule,  the 
acidity  of  the  contents  of  the  stomach  obtained  one  hour  after  the 
test-breakfast  ranges  between  4  to  6  or  6*5  c.  c. ;  results  above  or 
below  these  limits  are  j3athological.  It  is  a  matter  of  convenience 
to  express  the  acidity  in  percentage  according  to  the  amount  of  the 
deci-normal  soda  solution  used ;  thus,  for  example,  61  per  cent 
acidity  would  mean  that  100  c.  c.  of  filtered  stomach-contents  were 
neutralized  by  61  c.  c.  of  a  deci-normal  soda  solution.  This  j)re- 
vents  any  misconception  that  the  acidity  depends  on  free  hydro- 
chloric acid.  If  we  are  sure  that  the  acidity  depends  on  the  latter 
and  not  on  salts  or  any  other  acids,  we  may  express  the  value  as 
HCl.  One  cubic  centimetre  deci-normal  soda  solution  is  equivalent 
to  0'003646  HCl.  When  10  c.  c.  of  stomach-contents  are  used, 
multiply  0'03646  by  the  number  of  cubic  centimetres  added  from 
the  burette  till  the  contents  of  the  beaker  were  neutralized ;  this 
will  give  the  percentage  of  HCl  in  the  stomach-contents  under  ex- 
amination. Thus  in  the  present  specimen  the  actual  jDercentage  of 
HCl  is  0-22  per  cent ;  this  result  is  within  the  normal  limits  (0*14  to 
0*24  per  cent). 

To  determine  whether  the  acidity  depends  on  free  acids  or  acid 

salts,  the  aniline  dyes  will  be  found  the  most  useful ;  of  these  the 
best  is  TrojKeolin  00 — V orange  P airier  of  the  French.  This 
powder,  when  dry,  has  a  beautiful  orange  color ;  in  saturated  watery 
or  alcoholic  solutions  it  is  a  dark  yellowish-red ;  in  the  presence 
of  traces  of  free  acid — even  as  little  as  about  0*25  per  thousand 
[1  in  4,000] — it  changes  to  dark  brown,  but  acid  salts  make  it  straw 
yellow.  I  shall  take  a  small  quantity  of  the  reagent  and  add  a  few 
drops  of  dilute  HCl  (containing  about  0-05  per  cent  pure  HCl) ; 
as  you  see,  the  solution  at  once  assumes  a  deep,  dark-brown  color. 
If  some  acid  sodium  phosphate  is  added  to  the  tropseolin  solution. 


use,  the  lower  extremity  is  closed  with  the  well-greaserl  glass  coTer.  In  this  way 
we  avoid  the  annoying  drying  of  the  stop-cock  and  also  the  alteration  due  to  ex- 
posure to  the  air  which  occurs  in  the  ordinary  form  in  the  drops  of  fluid  in  the 
lower  end,  if  the  burette  is  not  in  continual  use  ;  this  change  is  due  to  the  formation 
of  carbonates. 


24  DISEASES  OF   THE  STOMACH. 

tlie  color  turns  not  brown,  but  a  light  straw  yellow.  Thus  tropseolin 
enables  us  to  determine  whether  free  acids  (hydrochloric  or  lactic) 
are  present. 

The  dye  called  Congo-red^  which  was  introduced  by  Hoesslin,* 
has  a  similar  action ;  its  solutions  assume  a  peach  to  a  brownish-red 
color.  The  addition  of  a  free  acid  changes  it  to  a  sky-blue.  It  is 
more  delicate  than  troj)seolin,  and  will  react  to  a  fluid  containing 
but  0*02  per  thousand.     Acid  salts  jDroduce  no  change. 

\_Benzopur2Juri71  was  introduced  by  v.  Jaksch ;  f  it  is  used  on 
stri|)s  of  filter-paper  which  have  been  dipped  into  a  saturated  aque- 
ous solution  of  benzopurpurin  6B,  and  dried.  Such  a  strip  is 
dipped  into  the  stomach-contents,  and  if  the  paper  at  once  assumes 
a  deep  blackish-blue  color,  then  there  is  more  than  04  per  cent 
PICl ;  if  the  color  is  more  of  a  brownish  black,  then  it  may  indicate 
either  organic  acids  or  a  mixture  of  these  acids  and  HCl.  To  dif- 
ferentiate, the  strip  of  paper  is  placed  in  a  test-tube  with  ether : 
if  the  color  remains  unchanged,  only  HCl  is  present ;  if  it  disap- 
pears, then  only  organic  acids  are  there  ;  if  it  becomes  less  marked, 
then  both  kinds  of  acids  are  present.] 

In  these  tests,  as  well  as  all  the  other  reactions  to  be  mentioned 
later,  there  must  be  an  excess  of  the  fluid  to  be  tested  over  the  color 
solution ;  otherwise  delicate  changes  might  escape  notice.  The 
best  method  is  to  pour  5  to  10  drops  of  the  color  solution  into  a 
small  test-tube,  and  then  add  1  to  2  c.  c.  [15  to  30  drops]  of  the 
filtered  stomach-contents.  The  delicacy  of  all  these  reactions  is 
markedly  affected  by  the  presence  of  salts  and  albuminoids,  espe- 
cially albumose  and  peptone.  Certain  salts,  as,  for  example,  sodium 
chloride,  enter  into  combinations  with  the  dyes  which  are  very 
stable,  even  though  they  are  not  true  chemical  compounds,  and  not 
even  the  addition  of  small  quantities  of  acid  suffices  to  break  them 
up  again  ;  on  the  other  hand,  albumen  and  its  derivatives  form  un- 
stable combinations  with  a  portion  of  the  free  acid,  and  thus  also 
disturb  the  reaction.     Yet,  at  all  events,  we  can  roughly  estimate 

*  Von  Hoesslin.  Ein  neiies  Reagent  auf  freie  Sauren.  Miinch.  med.  Wochen- 
schr.,  No.  6,  188G. 

f  [Von  Jaksch.  Klinische  Diagnostik  innerer  Krankheiten.  2.  Auflage,  1889, 
S.  123.— Tr.] 


THE   DETERMINATION   OP   HYDROCHLORIC   ACID.  25 

whether  we  are  dealing  with  free  acid  or  acid  salts,  and  can  obtain 
an  approximate  idea  of  the  amount  of  free  acid  by  the  intensity  of 
the  reaction. 

Let  us  test  whether  this  specimen,  whose  acidity  is  61  per  cent 
(=  0*2  per  cent  HCl),  contains  free  acid.  I  shall  first  add  some  to 
the  Congo-red  solution  ;  it  assumes  a  pale-blue  color,  but  its  inten- 
sity is  much  less  than  this  control  test  with  a  0*2  per  cent  hydro- 
chloric-acid solution.  The  same  difference  is  observed  in  the 
reactions  with  tropseolin.  Therefore,  along  with  the  free  acid 
which  is  present  in  this  specimen  there  are  also  acid  salts. 

How  can  we  determine  the  nature  of  the  free  acids  ? 

For  the  Determination  of  Hydrochloric  Acid,  we  must  first  con- 
sider those  aniline  dyes  which  in  aqueous  or  alcoholic  solution  react 
with  distinct  changes  of  color  to  free  acids  in  general,  and  to  free 
hydrochloric  acid  as  well.  From  the  chemical  composition  of 
methyl-violet,  Klemperer  *  concludes  that,  so  far  at  least  as  this 
dye  is  concerned,  loose  combinations  are  formed  which  are  easily 
split  up  again  by  every  kind  of  organic  or  inorganic  bases  and  by 
the  albumens  and  their  derivatives,  so  that  the  original  color  re- 
turns ;  or,  in  other  words,  as  I  have  already  expressed  it,  these 
substances  mentioned  above  have  a  greater  affinity  for  hydrochloric 
acid  than  methyl-violet  has.  Of  tropseolin  and  Congo-red  I  have 
already  spoken.  Another  dye  is  methyl-violet^  which  is  used  in 
an  aqueous  solution,  which  is  diluted  till  it  has  a  reddish-violet 
color.  The  addition  of  even  0-024  per  cent  of  HCl  to  the  solution 
changes  the  tint  to  a  sky-blue,  which  you  will  observe  has  a  differ- 
ent color  than  the  original  when  I  hold  both  tubes  up  to  the  light. 

Emerald^  smaragd,  or  malachite  green  is  also  employed ;  its 
solutions  are  dark  green,  playing  somewhat  into  a  bluish-green.  The 
addition  of  free  HCl  changes  it  to  a  beautiful  moss-green.  This  dye 
is  probably  identical  with  vert  hrillant,  so  warmly  recommended  by 
Lepine.  But  my  experience  has  been  that  smaragd-green  is  not  as 
delicate  as  methyl-violet  or  Congo-red.  Even  less  delicate  is  fiicJi- 
sin,  also  called  ruhin  /  its  solutions  are   bright  red,  but  turn  yel- 


*  G-.   Klemperer.    Zur  chemischen  Diagnostik  der  Mageiikrankheiten.     Zeit- 
schrift  f.  klin.  Med.,  Bd.  xiv,  S.  156, 


26  DISEASES  OF   THE  STOMACH. 

low  on  adding  an  acid ;  bnt  a  relatively  large  amount  of  acid  is 
needed  to  produce  tliis  cliange.  It  is  only  after  adding  a  large' 
quantity  of  a  solution  wliicli  has  double  the  amount  of  acid  used 
in  the  former  tests  that  the  color  begins  to  assume  a  lighter  shade 
and  finally  becomes  yellow. 

The  best  dyes  for  general  use  are  Congo-red  and  tropseolin, 
either  in  solution  or  as  test-paper,  like  those  which  I  now  show 
you  ;  these  test-paj^ers  are  made  by  dipping  strips  of  filter  -  jDaper 
into  a  saturated  solution  of  the  dye  and  allowing  them  to  dry.  The 
reaction  is  made  more  distinct  by  carefully  warming  them  over  a 
flame  (Boas) ;  Congo-red  paper  in  the  presence  of  small  quantities 
of  free  acid  assumes  a  lilac  color  at  the  place  heated.  The  same 
result  may  be  obtained  by  pouring  a  few  drops  of  the  color  solu- 
tion into  a  porcelain  dish  and  distributing  it  into  a  thin  layer  by 
rotating  it  to  and  fro  (Uffelmann).  Then  a  few  drojDS  of  the  fluid 
to  be  tested  are  added,  heat  is  gently  applied,  and  a  good  reaction 
is  readily  obtained.  Kahler  *  recommends  sucking  up  some  of  the 
filtered  stomach-contents  into  a  fine  glass  tube,  and  then  carefully 
adding  [by  suction]  a  few  drops  of  the  color  solution,  so  that  two 
layers  are  formed.  The  reaction  is  manifested  by  a  delicate  ring 
at  the  line  of  contact  of  the  two  fluids.  It  depends  upon  bringing 
together  suitable  quantities  of  the  fluid  and  the  dye  in  such  a  way 
that  the  change  in  color  may  be  visible ;  where  the  quantities  are 
small  this  can  naturally  be  done  more  easily  in  a  porcelain  dish 
than  in  the  bottom  of  a  test-tube.  The  principle  is  the  same, 
however. 

The  reaction  of  these  aniline  dyes  toward  hydrochloric  acid  is 
somewhat  uncertain,  because  they  are  decolorized  by  other  acids, 
especially  the  organic ;  as  I  have  already  shown,  their  delicacy 
is  also  affected  by  other  substances.  Unfortunately,  these  sub- 
stances are  the  ones  which  we  always  encounter  in  the  stomach- 
contents  during  ordinary  digestion — i.  e.,  albumen  and  its  deriva- 
tives, saliva  (an  albuminous  and  saline  fluid),  chlorides,  and  phos- 
phates ;  what  I  said  while  discussing  the  demonstration  of  free  acid 


*  Kahler.     Ueber  die  neuen  Methoden  zur  Untersuchung  des  kranken  Magens. 
Prager  raed.  Wochenschr.,  1887,  No.  32  u.  33. 


THE  DETERMINATION  OP  HYDROCHLORIC  ACID.  27 

is  also  true  here.  They  either  simulate  or  prevent  the  change  of 
color.  I  shall  now  show  you  on  a  solution  of  methyl-violet  that 
they  can  simulate  decolorization.  If  to  a  solution  of  tliis  dye 
I  add  some  diluted  white  of  egg  you  will  see  that  the  reddish-violet 
solution  will  assume  a  distinctly  different  blue  color.  A  slight  dif- 
ference in  this  color  and  that  produced  in  a  control  test  with  hy- 
drochloric acid  may  be  observed,  yet  this  can  only  be  detected 
when  the  two  tubes  are  held  alongside  of  each  other,  and  when  only 
pure  hydrochloric  acid  is  employed.  I  shall  now  pass  around  a 
third  tube,  in  which  both  HCl  and  albumen  have  been  added,  the 
result  being  a  shade  between  the  other  two.  By  holding  the  tubes 
up  to  the  light,  the  difference  and  similarity  can  be  distinctly  recog- 
nized. 

The  derivatives  of  albumen  act  in  exactly  the  same  way,  namely, 
the  various  albumoses,  syntonin,  propej)tone,  peptone,  leucin,  and, 
finally,  certain  salts,  especially  sodium  chloride,  which  is  so  abundant 
the  food.  If  to  a  methyl-violet  solution  some  concentrated  com- 
mon-salt solution  (even  a  5  to  10  per  cent  solution  will  suffice) 
is  added,  the  reaction,  when  some  acid  stomach-contents  or  pure 
HCl  is  poured  in,  is  much  less  distinct,  or  may  even  be  absent.  On 
the  other  hand,  the  bluish  color  of  the  methyl-violet  solution  after 
adding  HCl  will  disappear  on  pouring  in  a  definite  proportionate 
amount  of  a  solution  of  albumen,  albumose,  peptone,  etc. ;  or  the 
color  change  may  not  occur  at  all  if  these  substances  have  been  add- 
ed to  the  HCl  before  using  it.  I  say,  "  in  proper  proportion,"  and 
therel)y  I  also  explain  the  entire  phenomenon  from  whose  varying 
distinctness  with  different  reagents  false  deductions  have  been 
drawn  as  to  their  greater  or  less  usefulness.  Under  the  above  con- 
ditions it  was  only  necessary  for  the  substances  in  question  to  com- 
bine with  the  acid  to  form  unstable  compounds  with  it  or  to  absorb 
part  of  it ;  hence  it  can  no  longer  react  as  a  free  acid.  Therefore, 
in  making  comparative  tests  with  solutions  of  acids  which  exceed 
the  sensitiveness  of  a  reagent,  the  more  delicate  the  reagent  the 
greater  is  the  amount  of  the  above-named  substances  [albumen, 
etc.]  which  may  be  added  without  preventing  the  reaction ;  the 
opposite  result  will  be  observed  if  we  are  working  with  solutions 
which  still  contain  even  a  trace  of  acid  to  act  ujDon  the  reagent. 


28  DISEASES  OP  THE  STOMACH. 

This  enables  us  to  understand  the  statement  made,  for  example,  by 
Seeman,*  that  a  combination  of  equal  parts  of,  a  -J-per-cent  peptone 
solution  and  a  0"2-per-cent  HCl  mixture  will  just  give  the  methyl- 
violet  reaction  ;  while  Krukenberg  f  claims  that  the  phloroglucin 
reagent  (see  p.  29)  will  do  the  same  when  one  part  of  a  4:-per-cent 
peptone  solution  is  added  to  two  parts  of  the  identical  HCl  mixt- 
ure. It  simply  means  that  methyl-violet  is  about  four  times  less 
sensitive  than  phloroglucin-vanillin. 

The  other  dyes  act  just  like  methyl-violet ;  some — e.  g.,  tropse- 
olin — are  more  markedly  affected  by  salts,  while  others,  like  sma- 
ragd-green  and  Congo-red,  by  albumens.  When  we  are  using  im- 
pure acids,  or  especially  stomach-contents,  which  always  have  a 
slight  tinge  of  color,  this  behavior  of  the  dyes  may  give  rise  to  seri- 
ous errors,  and  is  certainly  the  cause  of  many  of  the  controversies 
which  have  arisen  in  discussing  these  results.  As  early  as  1880  I 
called  attention  to  this,:|:  and  sliowed,  especially  concerning  the 
methyl-violet  reaction,  that  "  it  was  delayed  by  the  presence  of  even 
small  quantities  of  blood,  and  that  it  was  markedly  enfeebled  or 
even  prevented  by  solutions  of  hydrochlorate  of  leucin  and  tyrosin 
as  well  as  by  albumen  and  peptone."  I  shall  demonstrate  to  you  on 
this  somewhat  turbid  sample  of  stomach-contents  (obtained  from 
a  different  patient)  that  a  distinct  bluish  color  will  be  given  by 
methyl- violet,  which  is  nevertheless  not  due  to  free  acid ;  for,  if  I 
test  for  the  latter  with  trop8e.olin,  although  a  darkening  or,  rather, 
a  clouding  of  the  reagent  occurs,  yet  there  is  no  true  brown  color. 
Free  acid  is  therefore  absent  in  spite  of  the  change  of  color  pro- 
duced by  the  methyl-violet.  The  organic  acids  which  have  been 
alluded  to  above  as  affecting  the  color  solutions  include  lactic  acid, 
acetic  acid,  and  butyric  acid ;  yet,  in  order  to  simulate  the  changes 
produced  by  HCl,  much  stronger  solutions  are  requisite  than  are 
found  in  the  stomach-contents.  Where  HCl  and  the  above  organic 
acids  occur  together,  the  delicacy  of  the  HCl  reaction  is  not  affected 

*  Seeraan.  Ueber  das  Vorhandensein  freier  Salzsaure  im  Magen.  Zeitschr.  fiir 
kliii.  Med.,  Bd.  v,  1882. 

f  Krukenberg.  Ueber  die  diagnostiche  Bedeiitung  des  Salzsaurenachweises 
bei  Magenkrebs.    Inaug.  Dissert.     Heidelberg,  1888. 

X  Ewald.  Ueber  das  angebliehe  Fehlen  freier  Salzsaure  im  Magensaft.  Zeit- 
schr. fur  klin.  Med.,  Bd.  i,  S.  622. 


MOHR'S  REAGENT.  29 

by  the  latter.  Concerning  tliis  I  have  constructed  a  table  which 
will  be  found  at  the  end  of  this  lecture. 

This  behavior  of  the  aniline  dyes  showed  the  desirability  of 
other  tests  in  which  these  sources  of  error  would  not  arise.  The 
test  proposed  by  Molir  depends  on  the  change  wdiich  occurs  in  a 
solution  of  sulphocyanide  of  potassium  and  acetate  of  iron  on  the 
addition  of  HCl ;  this  is  due  to  the  formation  of  sulphocyanide  of 
iron,  which  varies  in  color  from  a  peach-red  to  a  brownish  red. 
Two  c.  c.  [f  3  ss.]  of  a  10-per-cent  solution  of  sulphocyanide  of  potas- 
sium are  added  to  0'5  c.  c.  ['niviij]  of  a  neutral  solution  of  ferric 
acetate  (the  liquor  ferri  acetici,  Pharm.  Germanic,  which  contains 
between  4  and  5  per  cent  of  iron) ;  this  is  diluted  with  water  to  20 
c.  c.  [f  3  vjss.],  so  that  the  fluid  assumes  a  light  mahogany  color.  A 
little  of  this  is  poured  into  a  test-tube  and  some  dilute  hydrochloric 
acid  is  added ;  the  color  of  the  solution  then  changes  to  a  dark 
brown-red.  This  method  is  not  so  distinct  as  when  tried  with  a  thin 
layer  in  a  porcelain  dish.  A  few  drops  of  the  reagent  are  placed  in 
a  small  porcelain  dish  and  spread  into  a  thin  layer  by  rocking  the 
dish  to  and  fro,  and  pouring  off  the  excess.  A  little  hydrochloric 
acid  is  allowed  to  trickle  slowly  from  the  edge  of  the  dish ;  at  the 
point  of  contact  of  the  two  fluids  a  beautiful  peach-red  color  forms 
at  flrst,  but  on  adding  more  acid  it  assumes  a  brownish  tinge.  This 
peach-red  color  is  very  characteristic  and  enables  us  to  detect  very 
small  traces  of  hydrochloric  acid,  although  it  is  not  as  delicate  as  the 
aniline  dyes.  It  possesses  these  advantages,  that  it  is  disturbed  only 
by  larger  quantities  of  albuminates,  and  not  at  all  by  salts.  Instead 
of  always  preparing  the  solution  fresh,  strips  of  filter-paper  may  be 
dipped  into  it  and  dried,  and  the  reaction  may  be  obtained  with 
them.  But  these  papers  after  a  time  become  less  sensitive  as  a  re- 
sult of  contact  with  the  air. 

I  have  no  personal  experience  of  the  value  of  ultramarine  and  zinc 
sulphide  proposed  by  Kahler,*  because  I  considered  it  superfluous 
to  search  for  new  methods  after  the  announcement  of  Giinzburff's 
reagent.f    This  test,  which  surpasses  all  of  those  thus  far  mentioned, 

*  Kahler.     Ueber  die  neuen  Methoden  zur  Untersuchung  des  kranken  Magens. 
Prager  med.  Wochenschr.,  1887,  No.  32 ;  and  Kraus,  ibid.,  1887,  No.  53. 
t  Gunzburg.    Centralblatt  fiir  klinische  Medicin,  1887,  No.  40. 


30  DISEASES  OP   THE  STOMACH. 

is  so  sharp  and  at  the  same  time  so  simple  and  positive  Lhat  a  con- 
trol test  with  other  reagents  is  necessary  in  only  very  few  cases  in- 
deed. According  to  my  extensive  experience  thus  far,  using  it 
daily  and  comparing  it  with  other  tests,  I  do  not  hesitate  to  pro- 
nounce Giinzburg's  reagent  very  valuable ;  my  original  recommen- 
dation of  it*  has  in  the  mean  time  been  corroborated  by  many 
other  writers.  The  j^rinciple  of  the  reaction  is  that  a  pine-needle 
which  has  been  dipped  into  a  solution  of  phloroglucin  will  assume 
a  bright  red  color  when  it  is  brought  in  contact  with  hydrochloric 
acid.  Max  Singer  has  shown  that  this  color-change  is  due  to  the 
presence  of  vanillin.     The  solution  is  made  as  follows : 

Phloroglucin 2*0  [gr.  xxx] 

Yanillin 1-0  [gr.  xv] 

Absolute  alcohol SO'O  [f  3  j] 

The  solution  is  jDale  yellow  in  color,  and  has  a  pronounced  odor  of 
vanilla  or  fresh  pine-wood ;  on  exposure  to  light  it  in  time  assumes 
a  dark  golden-yellow  color,  and  it  must  therefore  be  kejDt  in  black 
bottles.  If  a  drop  of  the  reagent  is  put  into  a  small  porcelain  dish 
and  some  concentrated  hydrochloric  acid  is  added,  a  bright  red 
color  and  the  formation  of  small  red  crystals  will  be  at  once  ob- 
served. If  the  acid  is  weaker,  as,  for  example,  only  0*05  per  cent 
or  less,  or  with  stomach-contents,  no  change  will  be  observed  at  first ; 
but  if  the  dish  is  carefully  heated  over  a  flame,  so  that  the  fluid 
does  not  boil,  but  simply  evaporates  slowly,  at  the  edge  of  the  drop 
a  bright  red  tinge  or  very  delicate  red  stripes  will  be  observed. 
These  are  absolute  proofs  of  the  presence  of  free  hydrochloric  acid. 
Blowing  on  the  dish  will  cause  the  beautiful  red  stripes  to  appear  at 
once.  Filtration  of  the  gastric  contents  is  unnecessary  ;  one  or  two 
drops  in  a  small  dish  or  on  a  stri^)  of  filter-paper  with  an  eqnal 
quantity  of  the  reagent  will  suffice.  The  reaction  has  this  great  ad- 
vantage over  all  others,  that  it  is  not  simulated  by  the  albuminates 
which  may  be  present ;  neither  is  it  interfered  with  by  salts,  pro- 
vided they  are  within  the  usual  proportion ;  nor  is  it  afliected  by 
organic  acids  ;  but  of  this  I  shall  speak  again  later  on.     Its  delicacy 


*  Ewald.    Verhandlungen  des  Vereins  f  llr  innere  Medicin  zu  Berlin.     Deutsch. 
med.  Wochenschr.,  1887,  No,  46. 


GtTNZBURG'S  REAGENT.  31 

far  surpasses  every  other  reagent.  Tropaeolin  papers  fail  when 
hydrochloric  acid  is  below  0'3  per  mille  [1  in  3,300]  ;  but  I  am 
convinced,  that  Giinzburg's  reagent  may  be  used  when  it  is  as  low 
as  0-05  per  mille  [1  in  20,000]. 

The  color  obtained  is  always  a  bright  red,  but  where  the 
amounts  are  very  small  it  may  be  a  pale  rose-red,  yet  it  is  never 
brown  nor  brownish  yellow  nor  brownish  red.  The  presence  of 
such  shades  indicates  overheating  and  the  combustion  of  organic 
substances.  Characteristic  is  the  appearance  of  red  stripes  or  of  a 
uniform  reddish  tinge  at  the  edge  of  the  drop  after  gentle  heating 
or  slow  evaporation  to  dryness.  Strong  heating  and  evaporation  of 
any  albuminous  substance  will  produce  a  marked  central  red  colora- 
tion, yet  this  is  scarcely  to  be  confounded  with  hydrochloric-acid 
reaction.  If  dilute  hydrochloric  acid  is  added  to  solutions  of  albu- 
men or  peptone,  then  the  above-mentioned  reaction  of  these  sub- 
stances will  only  occur  after  their  affinity  for  the  acid  has  been 
completely  satisfied. 

The  behavior  of  the  reaction  will  afford  a  fairly  good  quantita- 
tive estimation  of  the  amount  of  free  hydrochloric  acid  ;  an  easy 
and  reliable  method  for  this  has  thus  far  been  lacking.  -  By  suc- 
cessively diluting  the  stomach-contents  which  react  to  Giinzburg's 
reagent  to  ^,  -|-,  ^,  etc.,  till  the  reaction  is  no  longer  obtained,  we 
can  approximately  estimate  the  quantity  of  actually  free  hydro- 
chloric acid,  since  we  know  that  the  limit  of  the  reaction  lies  at 
-^^  per  mille  [1  :  20,000].  For  example,  the  red  color  is  just  visible 
with  the  twentieth  dilution ;  then  the  gastric  juice  contains  1  per 
mille — i.  e.,  O'l  per  cent  of  free  hydrochloric  acid.  However,  we 
can  also  get  a  rough  idea  of  the  larger  or  smaller  amount  of 
free  acid  by  the  more  or  less  intense  red  color  while  making  the 
test. 

Boas*  discovered  that  resorcin  was  a  substance  with  a  very 
similar  action.     The  reagent  consists  of  : 

*  Boas.  Ein  neues  Reagens  fiir  den  ISTachweis  freier  Salzsaure  im  Magensaft. 
Centralblatt  filr  klin.  Med.,  1888,  No.  45.  [Also,  Boas.  Diagnostik,  etc.,  2te  Auflage 
1891,  S.  134.  This  test  may  also  be  applied  by  means  of  strips  of  filter-paper  which 
are  dipped  into  the  stomach-contents ;  add  one  to  two  drops  of  reagent  and  heat 
gradually.  It  is  slower  than  Giinzburg's  reagent,  and  requires  greater  delicacy  in 
using  it. — Tr.] 


32  DISEASES  OF  THE  STOMACH. 

Resorcin  resublimat 5*0  [gr.  Ixxv] 

Saccliar.  alb 3'0  [gr.  xlv] 

Spiritus  dilut 100-0  [f  ^  iijss.] 

Tliree  to  five  drops  of  the  reagent  are  poured  into  a  porcelain  dish 
and  an  equal  quantity  of  stomach-contents  is  added ;  it  is  now  heated 
slowly,  when  a  purple-red  color  appears  at  the  edge  of  the  drop,  as 
in  Giinzburg's  test,  even  in  the  presence  of  only  0*05  per  mille  of 
free  HCl.  This  reaction  is  also  produced  only  by  hydrochloric  acid, 
and  is  never  caused  by  organic  acids. 

Having  thus  spoken  of  all  the  more  important  means  for  de- 
tecting free  hydrochloric  acid,  we  conclude  that  for  simplicity  and 
distinctness  the  reagents  of  Giinzburg  and  Boas  and  tropseolin  are 
to  be  considered  the  best.  We  must  next  consider  the  other  acids 
which  are  found  in  the  stomach-contents— how  they  are  to  be  de- 
tected, and  what  are  their  relations  to  and  reciprocal  action  upon 
hydrochloric  acid.  At  all  events,  the  discussion  of  the  color-tests 
for  free  hydrochloric  acid  is  by  far  the  most  important,  but  it  may 
be  dismissed  for  the  present,  since  many  comparative  examinations 
have  been  made  by  various  observers — Reischauer,  Kraus,  Haas, 
Krukenberg,  and  others ;  their  conclusions  as  to  the  relative  value  of 
the  difEerent  tests  agree  fairly  well.  In  a  recent  dissertation  Ivuhn  * 
arranges  these  substances  according  to  their  increased  sensitiveness 
towards  pure  hydrochloric  acid ;  yet  it  by  no  means  follows  that 
the  same  order  is  true  when  applied  to  stomach-contents.  He  tab- 
ulates them  thus  :  Ultramarine-blue,  tropseolin  paper,  Congo  paper, 
emerald-greeii,  methyl-violet,  tropseolin,  phloroglucin-vanillin,  Congo 
solution. 

I  shall  now  consider  the  Determmation  of  the  Organic  Acids — 
i.  e.,  lactic  acid,  acetic  acid,  and  the  true  fatty  acids,  especially  bu- 
tyric acid.  After  it  had  been  positively  settled  that  the  true  and 
only  acid  produced  by  the  gastric  glands  was  hydrochloric  acid, 
the  opinion  for  a  long  time  prevailed  that  the  occurrence  of  organic 
acids,  especially  lactic  acid,  was  always  pathological.  The  recent 
investigations  of  Dr.  Boas  and  myself,  which  were  conducted  on 


*  Kuhn.     Ueber  den  Werth  der  Farbstoffreagentien,  etc.     Inaug.  Dissert.    Gies- 
sen,  1887. 


LACTIC  ACID.  33 

living  subjects  with  liealtliy  stomachs,  definitely  proved  that  an 
organic  acid  also  exists  normally  in  the  early  stages  of  digestion. 
If  organic  acids  are  found  in  the  later  stages  in  such  quantities 
that  they  can  be  detected  with  the  ordinary  reagents,  then  they 
always  have  a  pathological  significance.  These  organic  acids  are 
the  results  of  a  normal  fermentation  of  some  of  the  substances  acted 
on  by  the  gastric  juice — starch,  sugar,  and  albuminous  bodies.  As 
far  as  we  know  at  present,  sarcolactic  acid  is  to  be  regarded  as  a 
constant  constituent  of  meat,  from  which  it  is  dissolved. 

Lactic  Acid. — There  are  two  kinds  of  lactic  acid,  fermentation 
lactic  acid  and  sarcolactic  acid.  They  are  distinguished  not 
so  much  by  diiferences  in  chemical  character  as  by  their  source. 
The  former  is  of  more  importance  to  us  than  the  latter,  yet  the 
tests  to  be  described  presently  apply  to  both  kinds.  The  method 
used  by  chemists  to  determine  the  presence  of  lactic  acid  is  a  very 
elaborate  one,  and  is  too  complicated  for  general  use.  A  very  sim- 
ple and  rapid  test  for  medical  practice  has  been  proposed  by  Uffel- 
mann.  Diluted  solutions  of  neutral  ferric  chloride  turn  canary-yel- 
low in  the  presence  of  lactic  acid.  If  I  take  some  ferric  chloride  and 
dilute  it  till  it  is  almost  colorless,  and  then  add  a  trace  of  lactic  acid, 
you  will  see  this  canary-yellow  color  at  once  appear.  Nevertheless, 
the  reaction  is  somewhat  uncertain,  or  rather  difficult  of  recognition, 
because  we  must  merely  distinguish  the  intensity  of  otherwise  simi- 
lar shades  of  color.  Hence  the  test  was  modified  as  follows :  a 
few  drops  of  a  diluted  neutral  ferric  chloride  solution  are  mixed 
with  one  or  two  drops  of  pure  carbolic  acid,  or  about  10  c.  c.  [  3  ijss.] 
of  a  2  to  5  per  cent  solution  of  carbolic  acid — the  exact  proportions 
are  not  essential — and  water  added  till  the  solution  assumes  a  beau- 
tiful amethyst-blue  color.  A  few  drops  of  even  a  0'05  jDer  thou- 
sand solution  of  lactic  acid  [1  in  20,000]  will  sufiice  to  change  this 
blue  to  the  characteristic  yellow  color.  The  delicacy  of  the  reac- 
tion is  such  that  2  c.  c.  [  3  ss.]  of  this  Uffelmann's  reagent  will  give 
a  distinct  result  on  adding  0"8  c.  c.  [12  minims]  of  a  lactic  acid  solu- 
tion of  O'Ol  per  cent ;  with  0'6  c.  c.  [9  minims]  of  the  same  solution 
the  color  is  pale  yellow ;  but  no  yellow  color  is  recognizable  on 
adding  only  0*3  c.  c.  [4|-  minims].  Unfortunately,  this  test  is  not  en- 
tirely free  from  sources  of  error,  since  lactates  as  well  as  free  lactic 


34  DISEASES  OP  THE  STOMACH. 

acid  produce  tlie  yellow  color.  This,  however,  does  not  mak^ 
much  diiference,  for  it  is  immaterial  to  us  whether  free  lactic  acid 
or  lactates  are  present ;  we  simply  wish  to  ascertain  the  presence 
of  lactic  acid  in  the  stomach.  But  the  reaction  can  also  be  caused 
by  alcohol,  sugar,  and  certain  salts,  especially  phos]3hates,  which 
are  frequently  found  in  the  contents  of  the  stomach.  If  I  add  to 
Uifelmann's  reagent  some  phosphate,  as  for  example  a  little  phos- 
phate of  soda  in  solution,  you  will  notice  a  change  to  a  canary- 
yellow  color,  which  is,  however,  diiferent  from  the  characteristic 
tinge  ;  but  if  the  stomach-contents  have  a  yellowish  hue  of  their 
own,  then  the  resemblance  may  be  very  close.  Under  such  cir- 
cumstances we  are  compelled  to  resort  to  a  modification  of  the 
method  used  by  chemists — i.  e.,  we  must  make  an  ethereal  extract 
of  the  fluid  to  be  examined,  then  evaporate  it  and  apply  the  reac- 
tion on  the  residue  left  after  evaporation.  This  method  is  very 
simple,  as  I  shall  now  show  you.  I  have  here  a  gastric  juice 
with  an  acid  reaction,  which  gives  a  marked  yellow  color  with 
UfEelmann's  reagent,  but  which  shows  no  reaction  for  free  acid 
with  tropseolin  ;  we  must  ascertain  whether  the  yellow  color  is 
due  to  traces  of  free  lactic  acid  or  lactates  or  acid  salts.  Lactic 
acid  may  easily  be  extracted  with  ether  from  solutions  of  O'YS  to 
0"5  per  thousand ;  hence,  if  free  lactic  acid  be  present,  the  aqueous 
solution  of  the  residue  left  after  evaporating  the  etliereal  extract 
ought  to  react  acid.  First,  we  extract  with  ether.  We  may  do 
this  by  using  a  so-called  "  separatory  funnel "  {Scheidetrichte^'),  or 
more  simply  by  thoroughly  shaking  about  2  to  5  c.  c.  [3  ss.  to 
3  jss.]  of  the  stomach-contents  with  ether ;  let  the  ether  separate, 
which  usually  occurs  very  rapidly,  and  pour  it  off  into  a  small  glass 
beaker.  This  is  repeated  with  fresh  portions  of  ether  till  we  have 
used,  all  told,  about  30  c.  c.  [f  §  j]  of  ether.  The  ether  is  then  evap- 
orated without  an  open  flame  by  placing  the  glass  beaker  in  a 
vessel  of  hot  water.  Add  a  few  drops  of  water  to  the  residue,  and 
with  this  try  UfEelmann's  reaction  by  carefully  letting  one  or  two 
drops  of  the  reagent  flow  from  a  pipette.  The  reagent  and  the 
substance  to  be  tested  must  always  bear  a  definite  relation  to 
each  other.  If  we  add  too  much,  the  reaction  might  be  concealed. 
Thus,  this  might  have  been  the  reason  why  Cahn,  of  Strassburg, 


FATTY  ACIDS— ACETIC   ACID— ALCOHOL.  35 

could  not  at  first  corroborate  my  statements  of  tlie  occurrence  of 
lactic  acid  in  the  digestion  of  meat.  The  residue  left  in  our  test 
is  acid,  and  gives  a  distinct  Uffelmann  reaction.  The  fact  that 
there  is  no  reaction  for  free  acids  with  tropseolin  shows  how 
much  more  delicate  Uft'elmann's  test  is  than  tropaeolin.  Whereas 
no  free  acid  could  be  detected  with  tropseolin  because  it  was  con- 
cealed by  acid  salts,  and,  even  then,  the  quantity  of  free  acid  was 
very  small,  yet  it  was  absolutely  demonstrated  with  Uffelmann's 
reagent.* 

The  fatty  acids,  and  especially  butyric  acid,  change  Uffelmann's 
reagent  to  a  tawny  yellow  color  with  a  reddish  tinge ;  but  this  oc- 
curs only  when  they  are  present  in  over  0"5  per  thousand  [1  in 
2,000].  Fat  in  the  stomach-contents  may  be  easily  recognized  by 
the  small  oily  particles  which  are  to  be  found  in  the  aqueous  solu- 
tion of  the  residue  left  after  evaporating  the  ethereal  extract.  The 
butyric  acid,  which  is  present  in  this  same  aqueous  solution,  may  be 
separated  in  the  form  of  oily  drops  by  adding  some  small  pieces  of 
calcium  chloride. 

The  best  practical  test  for  acetic  acid  is  the  nose.  If  present  in 
considerable  quantity,  its  odor  is  unmistakable.  It  may  be  detected 
by  neutralizing  the  watery  residue  of  the  ethereal  extract  with  car- 
bonate of  soda  and  then  adding  neutral  ferric  chloride  solution.  A 
beautiful  blood-red  color  is  struck,  which  can  only  be  obtained  by 
one  other  substance,  formic  acid,  but  this  does  not  occur  in  the  con- 
tents of  the  stomach. 

Finally,  one  other  substance — alcohol — is  to  be  mentioned ;  it  is 
to  be  found  only  in  the  rare  cases  of  marked  yeast  fermentation  in 
the  stomach.  It  may  be  detected  with  the  so-called  Lieben  iodo- 
form reaction  in  the  distillate  of  the  stomach-contents :  but  we  must 


*  [Leo  also  gives  a  not  too  complicated  method  for  testing  lactic  acid  and  lac- 
tates. All  the  volatile  acids  are  removed  by  boiling  the  stomach-contents  till 
litmus-paper  held  over  the  vessel  is  no  longer  reddened.  Replace  the  water  lost  by 
evaporation.  After  cooling,  pour  an  equal  quantity  of  ether  and  the  specimen 
into  a  test-tube,  close  the  opening  of  the  tube,  and  shake  thoroughly.  After  letting 
the  tube  stand  vertically  for  a  few  minutes  till  the  layers  have  separated,  suck  up 
the  ether-layer  with  a  pipette  and  put  it  into  a  watch-glass.  Evaporate  the  ether; 
dissolve  the  residue  in  water.  If  lactic  acid  is  present,  it  will  give  acid  reaction 
with  litmus  or  Congo-red,  or  show  Uffelmann's  reaction. — Leo.  Diagnostik  der 
Krankheiten  der  Verdauungsorgane.  Berlin,  1890,  S.  106. — Tr.] 
4 


36 


DISEASES  OF  THE  STOMACH. 


be  certain  tliat  the  patient  has  not  taken  alcohol  for  some  time, 
either  in  beverages  or  medicines  (tinctures,  fluid  extracts,  etc.). 

I  have  constructed  the  following  table  to  show  the  delicacy  of 
the  various  reagents  and  the  mutual  relations  and  disturbing  effects 
on  the  reactions  of  the  acids,  peptone,  and  salts.  Detailed  explana- 
tions are  unnecessary,  since  I  have  already  given  all  the  necessary 
data  in  the  early  part  of  this  lecture. 


Methyl-violet 

Tropseolin 

Smaragd-green 

Congo-red* 

GiJnzburg's  reagent.. 

Boas's  reagent 

Mohr's  reagent 

Uffelmann's  reagent. 


Reaction  Positive  in  the  Pbesencb  op 


Hydrochloric 
acid,  per 
thousand. 


0-24 

0-3 

0-4 

0-1 

0-05 

0-05 

1-0 


Lactic  acid, 
per  thousand. 


4 
Over  10 
10 
0-2 


0-1 


Butyric  acid, 
per  thousand. 


5  to  6 

Over  10 

Over  10 

0-4 


0-5 


All  the  above  reagents  give  qualitative  but  not  quantitative 
results.  To  obtain  the  latter,  which  are  not  essential  in  daily  prac- 
tice, we  are  compelled  to  resort  to  complicated  processes. 

At  the  outset  the  questions  must  be  answered:  first,  whether 
the  amount  of  free  hydrochloric  acid  is  to  be  estimated ;  secondly, 
whether  that  of  the  loosely  comhined  hydrochloric  acid  (see  above, 
page  28) — i.  e.,  that  portion  of  HCl  which,  although  secreted  by 
the  gastric  glands,  has  entered  into  combinations  with  bases  or  or- 
ganic substances ;  and,  finally,  whether  the  total  quantity  of  HCl 
is  to  be  ascertained.  As  has  already  been  repeatedly  stated,  under 
normal  conditions  every  time  food  is  introduced  into  the  stomach 
there  is  so  abundant  a  secretion  of  hydrochloric  acid  that  not  alone 
are  all  of  the  above-mentioned  affinities  satisfied,  but  there  is  even 
an  excess  (the  free  HCl).  Under  pathological  conditions  free  HCl 
is  not  infrequently  absent ;  it  must  then  be  determined  whether  any 
of  it  has  been  produced  in  the  stomach  at  all,  or  whether  it  has  only 
been  insufficient  in   amount.     Thus  the   quantity  of   free  hydro- 


*  HOsslin  i}.oc.  cit.)  gives  0-02  as  the  lowest  limit,  but  I  agree  with  Boas  (Deutsch. 
med.  Wochenschr.,  1887,  No.  39)  that  a  distinct  blue  color  of  the  Congo  paper  first 
occurs  when  the  proportion  is  as  above. 


ESTIMATION  OF  HYDROCHLORIC  ACID.  37 

chloric  acid  may  vary  under  different  conditions ;  lience  tlie  neces- 
sity of  ascertaining  its  amonnt. 

Estimation  of  Free  Hydrochloric  Acid. — This  may  be  done  ap- 
proximately in  the  absence  of  other  acids  (especially  lactic  and  fatty 
acids)  by  converting  the  acidity  found  by  titration  into  that  of  HCl 
(see  page  23),  Mintz's  method  ^  is  more  exact ;  deci-normal  soda 
solution  is  added  [from  a  burette]  to  10  c.  c.  of  the  filtered  stomach- 
contents  till  Giinzburg's  reaction  no  longer  occurs  /  here  the  quan- 
tity of  alkali  corres]3onds  to  the  amount  of  free  hydrochloric  acid 
which  is  present.  Mintz  has  estimated  the  limits  of  the  Giinzburg 
reaction  to  be  0'036  per  mille  HCl  (i.  e.,  1  c.  c.  deci-normal  soda 
solution  to  100) ;  he  has  also  demonstrated  by  special  experiments 
that  even  in  mixtures  of  albuminous  substances  and  hydrochloric 
acid  the  alkali  combines  first  with  the  free  HCl.  For  example,  if 
the  Giinzburg  reaction  no  longer  occurs  after  adding  1*3  c.  c.  deci- 
normal  soda  solution  to  10  c.  c.  stomach-contents,  and  is  still  posi- 
tive when  only  1*2  c.  c.  of  the  soda  solution  have  been  added,  then 
the  amount  of  free  HCl,  as  calculated  for  100  c.  c.  stomach-con- 
tents, equals  13  c.  c.  deci-normal  soda  solution  (i.  e.,  12  -|-  1) ;  this 
represents  0*047  per  cent  HCl.  f 

Estimation  of  Loosely  Combined  Hydrochloric  Acid. — It  is  evident 
that  in  this  way  by  reversing  the  process  we  can  ascertain  the 
amount  of  loosely  combined  hydrochloric  acid  in  stomach-contents 
containing  no  free  hydrochloric  acid.  A  deci-normal  hydrochloric- 
acid  solution  is  added  to  this  kind  of  stomach-contents  till  Giinz- 
burg's reaction  is  positive.  ]l^ow,  since  the  limit  of  this  reaction  is 
0*036  HCl  =  1  c.  c.  Y^o  normal  soda  solution,  then  the  difference 
between  this  and  the  amount  of  r^^  normal  HCl  solution  repre- 
sents the  quantity  of  combined  hydrochloric  acid  which  was  present. 
For  example,  if  Giinzburg's  reaction  was  positive  after  adding  0*7 
c.  c.  jig-  normal  HCl  solution  to  100  c.  c.  stomach-contents,  then 
1  —  0*7  =  0*3  c.  c.  is  the  amount  of  acid  which  was  already  present. 


*  S.  Mintz.  Eine  einfache  Methode  zur  quantitativen  Bestimmung  der  freien 
Salzsaure  im  Mageninhalt.  Wiener  klin.  Wochenschrift,  1889,  No.  20 ;  and  1891, 
No.  9. 

t  [13  X  0-003G46  (1  c.  c.  -^  normal  soda  solution  =  0-003646  HCl)  =  0-047398 
per  cent  HCl.— Tr.] 


38  DISEASES  OP  THE  STOMACH. 

Boas  *  and  Morner  have  soniewliat  modified  this  method ;  the 
stomach-contents  are  extracted  with  ether,  and  the  hmits  of  the  re- 
action are  then  determined  with  Congo-red,  either  in  solution  or  as 
test-paper  [10  c.  c.  of  stomach-contents  are  extracted  with  100  c.  c. 
ether].  If  the  former  is  used,  5  c.  c.  of  a  watery  solution  are  added 
to  an  equal  quantity  of  the  filtrate  of  the  stomach-contents;  the 
mixture  is  titrated  with  ^^  normal  soda  solution  till  the  blue  fluid 
assumes  a  red  color.  The  number  of  cubic  centimetres  of  the  soda 
solution  added  at  once  indicates  the  quantity  of  free  hydrochloric 
acid  which  is  present. 

Another  method  is  that  suggested  by  Leo  ;  f  this  is  based  upon 
the  fact  that  calcium  carbonate  is  not  decomposed  by  acid  phos- 
phates, but  with  free  hydrochloric  acid  it  forms  a  neutral  solution 
of  calcium  chloride. 

The  Estimation  of  Free  and  Loosely  Combined  Hydrochloric  Acid. 
— The  best  practical  method  is  that  of  Sjoqvist, :{:  as  modified  by 
Salkowski.*  If  a  mixture  of  organic  acids  and  free  or  loosely  com- 
bined hydrochloric  acid  be  treated  with  barium  carbonate,  evapo- 
rated to  dryness,  and  then  reduced  to  ash,  all  the  CI  combines  as 
barium  chloride,  which  is  soluble  in  hot  water.  The  organic  acids 
are  decomposed  and  form  barimn  carbonate,  which  is  insoluble  in 
water.  From  this  solution,  which  may  also  contain  inorganic  chlo- 
rine compounds,  the  barium  chloride  is  precipitated  as  barium  car- 


*  Boas,  Centralblatt  fur  klin.  Med.,  1891,  No.  2.  [Also  Boas's  Diagnostik,  etc, 
p.  134.— Tr.] 

■f  Leo.  Eine  neue  Methode  fiir  Salzsaurebestinimung  im  Mageninhalt.  Cen- 
tralblatt fiir  die  med.  Wissenschaft.,  1889,  No.  26. 

[This  method  is  carried  out  as  follows :  Moisten  a  strip  of  blue  litmus-paper 
with  gastric  contents  and  keep  this  as  a  standard.  A  few  drops  of  stomach-con- 
tents are  put  in  a  watch-glass,  and  a  small  amount  of  powdered,  chemically  pure 
calcium  carbonate  added ;  stir  up  with  a  glass  rod  and  test  the  reaction  with  blue 
litmus-paper.  Compare  this  with  the  standard.  If  the, litmus-paper  no  longer  red- 
dens, then  the  acidity  was  entirely  due  to  free  acid,  and  not  to  acid  salts ;  if  it  is 
less  red,  then  both  were  present ;  if  there  is  no  change,  then  there  are  only  acid 
salts,  while  free  acids  are  absent.  If  the  stomach-contents  have  previously  been 
extracted  with  ether  to  remove  lactic  and  fatty  acids,  then,  if  free  acid  is  found,  it 
is  hydrochloric  acid, — Tk.] 

X  Sjoqvist.  Eine  neue  Methode  freie  Salzsaure  im  Mageninhalte  quantitativ  zu 
bestiraraen,     Zeitschrift  fiir  physiologische  Chemie,  1888,  Bd.  siii,  S.  1. 

*  Fawizky.  Ueber  den  Nachweis  und  die  quantitative  Bestimmung  der  Salz- 
saure im  Magensaft,     Virchow's  Archiv,  Bd.  cxxiii,  S.  292. 


sjOqvist'S  method.  39 

bonate  by  adding  soda ;  it  is  collected  on  a  filter  and  is  once  more 
converted  into  BaCl,  by  adding  liydrocliloric  acid.  The  excess  of 
hydrochloric  acid  is  removed  by  evaporation  to  dryness;  the  dry 
residue,  which  has  a  neutral  reaction,  is  dissolved  in  water,  and  the 
BaClj  is  titrated  with  silver  nitrate  with  the  addition  of  potassium 
bichromate.  One  c.  c.  of  the  silver  solution  represents  O'OOl  sodium 
chloride,  and  the  quantity  of  hydrochloric  acid  may  be  calculated 
according  to  the  formula,  x  \  t  ^  36"5  :  58'5,  in  which  t  =  number 
of  cubic  centimetres  of  the  silver  solution  used. 

Accordingly,  the  examination  is  carried  out  in  the  following 
way :  Ten  c.  c,  of  the  filtered  stomach-contents  are  mixed  with  about 
0"5  gramme  barium  carbonate  in  a  platinum  capsule ;  the  fluid  is 
then  evaporated  to  dryness  and  reduced  to  ash.  After  cooling  the 
residue  is  dissolved  by  adding  50  to  YS  c.  c.  boiling  water  and  fil- 
tered. Several  drops  of  a  concentrated  soda  solution  are  added  to 
the  filtrate  [until  the  entire  BaClg  is  converted  into  BaCOg,  which 
is  thrown  down  as  a  flocculent  precipitate].  Again  filtration  ;  the 
precipitate  on  the  filter  is  collected  and  washed,  and  then  dissolved 
in  IICl  and  evaporated  to  dryness.  The  residue  is  dissolved  in 
water  and  titrated  with  the  silver  nitrate  solution  as  stated  above. 

The  various  manipulations  in  this  test  require  a  considerable 
length  of  time,  yet  the  actual  labor  is  not  great ;  it  is  not  as  compli- 
cated as  the  modification  proposed  by  von  Jaksch,*  in  which  the 
barium  chloride  is  converted  into  barium  sulphate  and  weighed  as 
such. 

Unfortunately,  recent  investigations  by  von  Pfungenf  and 
Leo  :j:  have  shown  that  Sjoqvist's  method  is  not  free  from  sources 
of  error,  since  the  presence  of  large  quantities  of  phosphates  or 
sodium  chloride  may  interfere  with  the  accuracy  of  its  results. 
However,  if  the  quantity  of  these  substances  in  the  test-meal  be  re- 
stricted as  far  as  possible,  in  spite  of  this  disadvantage  it  is  never- 

*  Von  Jakseh.  Sitzungsberieht  der  Akademie  der  Wissenschaften  in  Wien,  Bd. 
xcviii.     [Also  von  Jakseh.    Klinisehe  Diagnostik.    Translated  by  Cagney.  p.  lOl.J 

f  Von  Pfungen.  Ueber  den  quantitativen  Naehweis  freier  Salzsaure  im  Magen- 
safte  nach  der  Methode  von  Sjoqvist.  Zeitschrift  fiir  klin.  Med.,  Bd.  xix,  Supple- 
mentheft,  S.  224. 

:]:  Leo.  Beobaehtungen  zur  Saurebestimmiing  im  Mageninhalt.  Deutsch.  med. 
Wochenschrift,  1891,  No.  41. 


40  DISEASES  OP  THE  STOMACH. 

theless  the  best  and  most  reliable  method  for  estimating  the  quan- 
tity of  hydrochloric  acid  combined  with  organic  substances  and  that 
in  a  free  condition. 

A  process  which  is  even  more  complicated  is  that  proposed  by 
Hay  em  and  Winter.*  In  a  measured  quantity  of  stomach-contents 
these  investigators  estimate : 

a.  The  total  chlorine. 

h.  The  total  chlorine  minus  that  portion  which  is  volatilized 
after  prolonged  heating  at  100°  C. 

c.  The  fixed  chlorides  combined  with  mineral  bases. 

From  these  it  follows  that — 

a  —  h  ■=  free  hydrochloric  acid. 

5  —  c  =  hydrochloric  acid  combined  with  organic  bases 

and  ammonia. 
«  —  c  =  (a  —  5)  -j-  (5  —  c). 
Hence  each  trial  of  this  method  requires  three  determinations  of 
the  amount  of  chlorine ;  in  other  words,  many  hours  would  be 
needed  for  the  examination  of  a  specimen  of  stomach-contents. 
The  question  arises  whether  the  practical  value  of  the  result  will 
repay  one  for  the  labor  expended.  In  my  opinion,  this  is  not  the 
case,  because  it  is  of  no  importance  to  know  the  quantity  of  chlorine 
combined  with  mineral  bases,  or  the  absolute  amount  of  hydro- 
chloric acid  in  combination  with  organic  bases.  It  will  be  sufii- 
ciently  accurate  to  know  these  values  as  ascertained  with  the  com- 
bination of  the  methods  of  Sjoqvist  and  Mintz  or  Boas. 

*  Hayem  et  "Winter.    Du  Chimisme  Stomacale.     Paris,  1891,     [See  Amer.  Jour- 
nal Med.  Sciences,  September,  1891,  p.  282.— Tr.] 


LECTURE   II. 

METHODS    OF    EXAMINATION    (continued). DETERMINATION    OF    THE   DI- 
GESTION   OF    ALBUMEN   AND    STAECH. ABSORPTION    AND    MOTILITY. 

THE   TECHNIQUE    OF   THE   EXAMINATION   OF   THE    STOMACH. 

Gentlemen  :  The  action  of  the  digestive  ferment  pepsin  on 
albumen  is  manifested  by  a  series  of  characteristic  derivatives — the 
albuminates — concerning  which  I  shall  now  speak.  In  passing  I 
wish  to  call  your  attention  to  the  various  well-known  forms  in 
which  pepsin  is  artificially  prepared  by  different  manufacturers.  I 
show  you  here  a  fine,  dust-like  powder,  scales  or  lamellae,  and  also  so- 
called  granules.  Each  of  these  preparations  bears  a  label  indicating 
its  digestive  powers — i.  e.,  the  amount  of  albumen  which  is  dis- 
solved by  one  part  of  pepsin.  I  shall,  however,  refrain  from  pass- 
ing judgment  upon  the  relative  value  of  these  preparations,  since  it 
always  varies  according  to  the  care  in  the  manufacture.  First  one 
factory,  then  another,  heads  the  list ;  yet,  taken  all  in  all,  the  activ- 
ity of  these  preparations  does  not  vary  much.  Some  years  ago  I 
examined  and  compared  all  of  the  various  preparations,*  but  I  do 
not  know  whether  these  results  are  valid  to-day.  f 

The  essence  of  the  digestion  of  albumen  consists  in  the  well- 
known  transformation  of  the  various  kinds  of  this  substance,  of 
which  I  shall  only  mention  the  more  important  varieties — Qgg-, 
serum-,  and  plant-albumen,  fibrin,  and  casein — into  a  soluble  and 
easily  diffusible  form,  peptone.     In  another  place  :|:  I  have  already 

*  Ewald.    Zeitschr.  fur  klin.  Med.,  Bd.  i,  S.  236. 

f  [Recently  an  excellent  preparation  has  been  put  upon  the  market  in  the  form 
of  Fairchild's  glycerin  of  pepsin ;  it  is  essentially  a  glycerin  extract.  It  may  be 
administered  with  dilute  hydrochloric  acid,  and  thus  constitute  an  artificial  gastric 
juice.  It  is  also  free  from  the  disagreeable  odor  of  many  of  the  old  pepsin  products, 
and  keeps  indefinitely.     The  dose  is  from  5  to  30  drops. — Translator.] 

X  Ewald.    Klinik  der  Verdauungskrankheiten,  I.  Theil,  3te  Auflage,  S.  92,  etc. 


42  DISEASES  OP  THE  STOMACH. 

given  an  exact  description  of  this  change,  and  to-day  I  shall  restrict 
myself  to  the  practical  deductions  from  the  facts  known  to  ns.  You 
know  that  between  albumen  at  the  beginning  and  peptone  at  the 
end  of  the  process  of  albuminous  digestion  there  exist  certain  inter- 
mediate bodies  which  are  collectively  known  as  the  albumoses.  Of 
these  we  are  concerned  only  with  syntonin,  the  product  of  neutrali- 
zation, and  propeptone  or  hemialbumose.  Now  the  question  arises. 
What  significance  have  these  bodies  in  the  processes  of  digestion, 
and  by  what  tests  may  they  be  recognized  ? 

1.  Temperature. — Fluid  albumen  and  syntonin  coagulate  on 
warming — i.  e.,  heating  to  about  70°  C.  [158°  F.].  Propeptone  and 
peptone  are  not  coagulated  by  heat.  If  propeptone  is  precipitated 
from  its  solutions  in  the  cold  and  is  then  heated,  the  precipitate  re- 
dissolves,  but  is  again  deposited  on  cooling.  Temperature  has  abso- 
lutely no  influence  on  peptone. 

2.  Biuret  Reaction. — If  cupric  sulphate  is  added  to  propeptone 
and  peptone  in  an  alkaline  solution  in  the  cold,  an  intense  purple- 
red  color  is  observed,  the  so-called  biuret  reaction.  If  caustic  pot- 
ash and  dilute  cupric  sulphate  are  added  to  ordinary  albumen  and 
syntonin  without  warming,  a  more  or  less  marked  bluish-violet  color 
is  struck,  which  at  all  events  may  often  be  confounded  with  the 
biuret  reaction.  I  have  here  a  solution  of  peptone ;  I  add  some 
caustic  potash,  and  then  a  little  dilute  cupric  sulphate ;  you  will  ob- 
serve a  deep  purple-red  color,  which  is  distinctly  different  from  this 
bluish-violet  color  obtained  in  a  similar  way  with  a  solution  of  pure 
albumen.  The  same  is  true  of  propeptone,  as  I  can  show  you  with 
this  solution  of  Kemmerisch's  meat  peptone. 

3.  Precipitation. — Albumen  and  syntonin  are  precipitated  by 
saturated  solutions  of  sulphate  of  soda  or  common  salt  in  an  acetic- 
acid  solution,  hot  or  cold.  Syntonin  is  precipitated  from  acid  solu- 
tions as  soon  as  it  is  neutralized.  Propeptone  in  neutral  solution 
is  precipitated  in  the  cold  by  a  saturated  solution  of  common  salt 
or  rock  salt  on  adding  strong  acetic  acid  ;  it  is  soluble  when  heated. 
However,  a  portion  remains  in  solution,  and  can  only  be  precipi- 
tated by  the  addition  of  ammonium  sulphate  in  substance  or  in 
concentrated  solution.  Peptones  are  not  precipitated  by  the  above 
nor  by  the  following  reagents  which  throw  down  albumen,  syntonin, 


REACTIONS  OF  ALBUMEN,  ETC.  43 

and  propeptone :  cold  or  warm  nitric  acid,  acetate  of  lead,  acetic 
acid  with  ferrocyanide  of  potash,  metaphosphoric  acid,  ammonium 
sulphate. 

The  behavior  of  the  above-mentioned  substances  may  be  seen 
at  a  glance  in  the  following  tables  : 

Coagulated  by  heat ;  (  Albumen.        )  P^-ecipitated  by  saturated  solution  of  sulphate 

,.      ^'.       iQi-  rof  soda  or  common  salt  and  acetic  acid, 

no bmret reaction.  J  byntonin.        l  ,, 

V  !      cold  or  warm. 

Not  coagulated  by  r  p  ,  ^  Precipitated  cold  by  saturated  solution  of 

heat ;    biuret    re-  <  '    I      common  salt  and  strong  acetic  acid. 

action.  '  Peptone. 

'  Nitric  acid,  acetic  acid. 

Acetic  acid  and  ferrocyanide  of  potash. 

Acetate  of  lead. 

Metaphosphoric  acid. 

Ammonium  sulphate. 

Mercuric  chloride.  "] 

Phosphotungstic  acid.     1 

Phosphomolybdic  acid.  }■  Precipitate  peptone. 

Tannin.  I 

Mercuric  iodide.  J 


Precipitate       albu- 
men,      syntonin,  < 
and  propeptone. 


'Now,  what  are  the  practical  deductions  from  these  results  ? 

If  gastric  juice  containing  pepsin  and  hydrochloric  acid  be  al- 
lowed to  act  on  albumen,  after  a  certain  time  the  specimen  ought 
to  contain  the  various  modifications  of  albumen,  and,  according  to 
the  nature  and  strength  of  the  gastric  juice,  some  or  all  of  them  ought 
to  be  present.  The  results  of  such  an  examination  will  give  us  an 
indication  of  the  intensity  of  the  digestive  processes  in  the  stomach. 
Accordingly,  we  first  test  whether  the  stomach-contents  are  coagu- 
lable  by  heat.  If  they  are,  albumen  or  syntonin,  or  both,  may  be 
present ;  if  not,  we  may  find  propeptone  or  peptone.  If  the  reac- 
tion is  acid,  and  coagulation  occurs  on  heating,  we  must  neutralize. 
Should  a  precipitate  be  thrown  down,  it  is  syntonin.  If  this  is  filtered 
out  and  an  equal  quantity  of  concentrated  common-salt  solution  is 
added  to  the  filtrate,  and  then  acidulated  with  acetic  acid,  any  pre- 
cipitate thrown  down  which  is  redissolved  on  heating  is  due  to 
propeptone,  and  the  biuret  action  must  be  positive.  The  latter  pre- 
cipitate is  also  removed  by  filtration  ;  the  filtrate  is  treated  with 
acetic  acid  and  ferrocyanide  of  potash ;  if  no  precipitate  is  obtained, 
and  if  the  biuret  test  is  jDositive,  and  if,  furthermore,  precipitates 


4,4:  DISEASES  OP  THE  STOMACH. 

are  thrown  down  by  tannin  or  tlie  salts  of  tlie  heavy  metals,  or  by 
phosphotungstic  acid,  etc.,  then  peptone  is  present. 

Such  would  be  the  method  of  conducting  an  examination.  But 
the  question  naturally  arises.  What  is  the  practical  value  of  such  a 
demonstration  of  the  various  transformation-products  of  the  diges- 
tion of  albumen,  and  what  conclusions  can  be  drawn  in  regard  to 
the  pathology  of  the  cases  in  question  ? 

It  is  a  peculiar  fact  that  as  soon  as  the  digestion  of  albumen  has 
begun  as  the  result  of  the  action  of  pepsin  and  hydrochloric  acid, 
the  biuret  reaction  may  be  obtained  in  a  very  short  time.  This  may 
be  due  either  to  pro23e]3tone  or  peptone.  Let  us,  therefore,  briefly 
consider  the  relations  of  i)roiye2)tone  to  digestion. 

Is  it  absorbed  as  such,  or  is  it  simply  a  necessary  preliminary 
stage  of  peptone  %  Concerning  the  former  we  know  nothing ;  of 
the  latter  we  can  at  least  say  that  propeptone  seems  to  be  a  very 
frequent  but  by  no  means  a  constant  transformation-product  in  the 
digestion  of  albumen  by  pepsin  and  hydrochloric  acid.  On  the 
other  hand,  by  the  simple  action  of  hydrochloric  acid  upon  albu- 
men at  the  temperature  of  the  body,  syntonin  as  well  as  propeptone 
may  be  obtained.  Since  propeptone  will  give  the  biuret  reaction  as 
well  as  peptone,  the  simple  application  of  this  test,  as  has  been  done 
heretofore,  will  give  no  positive  proof  of  the  presence  of  peptone. 
The  best  way  is  to  precipitate  the  propeptone. 

As  the  result  of  investigations  conducted  in  my  laboratory,  Dr. 
Boas  *  has  shown  that  propeptone  is  absent  in  the  digestion  of 
meat,  but  is  present  in  the  digestion  of  plant  albuminates  and  pure 
egg-albumen.  Hence  it  is  by  no  means  an  essential  transformation- 
product  of  albumen.  ISTevertheless,  its  demonstration  is  important, 
since  it  is  always  present  in  the  ordinary  mixed  diet,  and  the  amount 
of  it  bears  some  relation  to  the  energy  of  digestion.  But,  after  all, 
our  main  object  is  to  ascertain  the  rapidity  of  the  peptone  forma- 
tion ;  this  could  be  most  readily  accomplished  by  making  a  quanti- 
tative estimation  of  the  amount  of  peptone  formed  during  diges- 
tion.    Unfortunately,  up  to  the  present  time  w^e  possess  no  simple 


*  I.  Boas.    Beitrage  ziir  Eiweissveidauung.    Zeitschr.  fiir  klin.  Med.,  Bd.  13, 
Heft  3. 


RELATIONS  OF  PROPEPTONE.  45 

and  reliable  metliod  for  tliis ;  *  and  even  if  we  did,  it  is  question- 
able wlietlier  j)athologically  we  would  derive  any  benefit  from 
it,  since  tlie  formation  of  peptone  rapidly  reaches  its  maximum 
and  then  appears  to  be  kept  steadily  at  tliat  point  by  special 
means.  Yet  this  is  by  no  means  proved.  According  to  our 
present  knowledge,  it  is  of  considerable  value  to  determine  and 
estimate  quantitatively  not  alone  the  final  but  also  the  intermedi- 
ate products  at  any  given  stage  of  the  digestion  of  albumen. 
The  demonstration  of  propeptone  is  valuable  for  this  purpose. 
The  more  marked  the  propeptone  reactions  are,  the  less  the  pep- 
tone which  has  been  formed  and  eventually  removed  from  the 
stomach. 

]^ow  we  have  found  that  in  an  ordinary  diet,  containing  an 
abundance  of  plant  albuminates,  and  after  the  test-breakfast,  the  di- 
gestion of  albumen  has  progressed  so  far  within  an  hour  that  propep- 
tone is  present  only  in  traces,  or  usually  is  not  to  be  detected  at 
all ;  whereas  in  abnormally  slow  digestion  it  is  still  abundant  at 
that  period.  We  may  also  approximately  estimate  the  amount 
of  peptone  by  the  intensity  of  the  biuret  reaction,  provided  we 
always  use  the  same  quantities  of  stomach  -  contents,  caustic  pot- 
ash, and  cupric  sulphate,  and  compare  it  with  the  reaction  given 
with  a  peptone  solution  of  known  strength.  But  it  has  been  ob- 
served that  the  biuret  reaction  is  equally  intense  where  at  the  same 
time  there  is  either  no  propeptone  or  where  the  amount  of  the  lat- 
ter is  very  variable.  In  other  words,  just  as  Cahn  f  found  in  the 
digestion  of  meat  in  dogs,  the  formation  of  j)eptone  remains  at  a  cer- 
tain percentage,  or  is  kept  at  that  figure  by  the  removal  of  the 
peptones  over  that  amount ;  in  such  cases  the  only  guide  to  the 
rapidity  and  amount  of  the  transformation  of  the  albumen  is  the 
amount  of  propeptone  formed  or  still  remaining,  l^aturally  there 
are  also  cases  in  which  the  peptone  formation  does  not  reach  the 
normal  height,  being  thus  entirely  insufiicient ;  for  this  reason  it  is 
advisable  to  make  the  test  for  propeptone  even  where  the  amount 
of  peptone  is  apparently  normal.     However,  according  to  recent 

*  [See  Boas.     Diagnostik,  etc.    3.  Aufl.,  p.  24.— Te.] 

f  A.  Cahn.    Die  Verdauung  des  Fleisches  im  normalen  Magen.     Zeitschr.  fiir 
klin.  Med.,  Bd.  13,  Hefte  1  und  2. 


46  DISEASES  OF  THE  STOMACH. 

investigations  made  by  Dr.  Gumlicli  and  myself,*  the  formation 

of  true  peptone  in  the  human  stomach  is  only  slight,  and  for  the 

most  part  the  transformation  of  albnmen  does  not  go  beyond  the 

albumoses.     At  all  events,  after  the  test-breakfast,  as  well  as  after 

larger  meals,  albumoses  predominate  in  the  stomach-contents,  and 

these  having  been  precipitated  by  ammonium  sulphate,  the  biuret 

reaction  is  feeble   and   much  less   marked  than  this   reaction  was 

before  the  albumoses  had  been  removed. 

Let  me  give  you  a  practical  example  of  the  use  and  value  of  the 

above : 

I  have  here  the  filtrate  of  the  stomaeh-coutents  of  a  ship-chandler 
from  H.,  who  has  been  under  my  observation  for  two  years.  There 
is  a  very  strong  suspicion  of  cai^cinoma  of  the  stomach,  yet  no  tumor 
can  be  demonstrated  ;  and  although  the  patient  apparently  digests  his 
food  well,  neither  has  disturbance  of  appetite  nor  complains  about  his 
digestion,  yet  he  has  emaciated  progressively.  Repeated  examinations 
failed  to  show  free  hydrochloric  acid  in  the  gastric  contents.  In  this 
filtrate,  also,  there  is  no  free  hydrochloric  acid,  although  the  reaction  is 
acid  and  the  biuret  reaction  is  well  marked.  Let  us  now  see  whether  the 
latter  is  due  to  peptone  or  propeptone.  I  neutralize  carefully,  add  an 
equal  quantity  of  concentrated  common-salt  solution,  and  then  a  little 
pure  acetic  acid.  There  is  not  the  slightest  trace  of  a  turbidity  ;  hence 
no  propeptone  can  be  present.  On  the  other  hand,  heating  causes  a  slight 
coagulation  of  albumen.  Thus  this  specimen  has  absolutely  no  free  hydro- 
chloric acid,  nor  have  repeated  examinations  in  the  past  few  years  at  any 
time  revealed  its  presence  ;  and  yet  this  gastric  juice  can  form  peptone, 
and,  as  it  seems,  in  a  fair  quantity.  You  will  remember  that  the  produc- 
tion of  peptone  may  occur  in  the  presence  of  other  acids,  especially  lactic 
acid  ;  f  with  Uffelmann's  reagent  I  can  show  you  large  quantities  of  lactic 
acid  in  this  specimen.  Hence  this  case  proves  that  pepsin  may  be  secreted 
or  formed  by  the  gastric  glands  independently  of  hydrochloric  acid,  as  I 
have  already  shown  in  another  patient,  and  as  Cahn  has  demonstrated 
in  dogs  which  have  been  deprived  of  chlorides  in  their  food.  J 

The  most  striking  feature  of  the  pepsin  and  hydrochloric  acid 
digestion  is  the  liquefaction  of  the  solid  albumen  {proteolysis).  The 
intensity  of  this  process  may  be  estimated  approximately  by  noting 
how  quickly  coagulated  albumen  is  liquefied.  We  may  do  this  by 
adding  small  pieces  of  coagulated  albumen  or  fibrin  to  the  filtered 

*  Ewald  and  Gumlich.     Berl.  klin.  Wochenschr.,  1890,  No.  44. 

t  Ewald.     Klinik  der  Verdauungskrankheiten.    I,  Theil,  3.     Auflage,  S.  110. 

X  Ewald.  Ein  Fall  von  Atrophia  der  Magensehleimhaut.  Berliner  klin.  Woch- 
enschr, 1886,  No.  32. —  Cahn.  Die  Magenverdauung  ini  Chlorhnnger.  Zeit- 
schrift  flir  physiolog.  Chemie,  1886,  Bd.  x. 


PROTEOLYSIS.  47 

contents  of  the  stomach,  and  observing  the  rapidity  of  their  liqne- 
faction  at  the  temperature  of  the  body. 

Coasulated  white  of  egg;  is  cut  into  thin  lamellae  with  a  double 
section  knife  [Valentine's  knife],  and  uniform  disks  are  cut  out 
with  a  cork-borer  or  some  similar  instrument  with  a  round,  hollow 
cutting  edge.  [A  short  piece  of  glass  tubing  will  do.]  By  preserv- 
ing these  disks  of  albumen  in  glycerin  they  are  ready  for  use  at 
any  time.  In  order  to  determine  in  a  given  specimen  of  stomach- 
contents  whether  the  pepsin  or  hydrochloric  acid  is  present  in  too 
great  or  too  small  amount,  an  equal  quantity  of  the  filtered  s^Deci- 
men  is  placed  in  four  small  test-tubes  and  one  or  two  disks  of  albu- 
men put  into  each.  To  the  first  nothing  else  is  added ;  to  the 
second,  enough  hydrochloric  acid  to  make  a  solution  of  about  0"3  to 
0*5  per  cent ;  this  is  accomplished  by  adding  two  drops  of  hydro- 
chloric acid  (Ph.  Germ.)  *  to  5  c.  c.  [f  3  ji]  of  stomach-contents. 
To  the  third  we  add  a  definite  quantity  of  pepsin,  about  0'2  to  0*5 
gramme  [gr.iij  to  gr.  vijss.] ;  to  the  fourth  add  both  hydrochloric 
acid  and  pepsin.  The  test-tubes  are  placed  in  an  incubator  kept 
at  about  100°  Fahr.  ;  from  time  to  time  we  look  to  see  how  far  the 
liquefaction  of  the  disks  of  albumen  has  proceeded.  The  rapidity 
of  this  liquefaction  will  at  once  inform  us  whether  digestion  would 
have  occurred  without  having  added  anything,  or  whether  acid  or 
pepsin  or  both  were  necessary.  Furthermore,  it  will  also  inform 
us  if  by  adding  more  hydrochloric  acid  to  the  filtered  gastric  juice 
we  have  made  the  acidity  too  strong.  In  this  way  we  can  judge 
which  factor  is  at  fault.  But  we  must  not  forget  that  after  the 
amount  of  peptone  has  reached  a  certain  percentage  its  further 
production  is  retarded,  or  even  suspended,  so  that  an  apparently 
slow  reaction  may  be  really  due  to  a  very  active  gastric  juice.  In 
this,  as  in  all  laboratory  experiments  on  digestion,  we  must  never 
forget  the  great  difference  between  them  and  the  natural  processes, 
and  that  in  our  flasks  and  test-tubes  we  can  never  imitate  the  ab- 
sorption on  the  one  hand,  and  the  removal  to  the  intestines  on  the 
other,  by  which  the  stomach  strives  to  maintain  a  fairly  uniform 

*  [Acidum  hydroehloricum  of  the  German  Pharmacopoeia  is  somewhat  feebler 
than  that  of  the  U.  S.  Pharm. ;  the  former  has  25  per  cent  pure  anhydrous  acid,  the 
latter  32  per  cent. — Tk.] 


48  DISEASES  OF  THE  STOMACH. 

degree  of  concentration  of  its  contents  ;  hence  all  our  tests  are 
fundamentally  deviations  from  Nature,  and  are  thus  to  a  certain 
degree  pathological. 

Glinzburg  *  and  Sahli  f  have  proposed  another  method  to  ascer- 
tain the  rapidity  and  intensity  of  the  digestion  of  albumen  and 
fibrin.  A  small  quantity  of  potassium  iodide,  0*1  to  0*2  gramme 
[gr.  jss.  to  iij],  is  inclosed  in  a  gelatin  capsule  or  gelatin  -  coated 
pill  or  in  a  thin  gum  packet  fastened  with  a  string  of  fibrin ;  if 
the  drug  is  introduced  into  the  stomach  in  one  of  these  ways,  the 
iodide  is  liberated,  and  can  be  absorbed  only  after  the  envelope  of 
fibrin  has  been  digested.  The  length  of  time  required  for  the  appear- 
ance of  the  potassium  iodide  in  the  saliva  or  urine  is  said  to  indicate 
the  thoroughness  of  gastric  digestion.  [See  p.  52.]  Unfortunately, 
not  alone  is  the  absorption  of  potassium  iodide  very  variable,  but  also 
the  rapidity  of  the  digestion  of  the  fibrin  capsule  does  not  bear 
any  direct  relation  to  the  presence  of  free  hydrochloric  acid  in  the 
stomach ;  for  in  some  cases  this  occurs  as  rapidly  in  the  absence  as 
in  the  presence  of  this  acid.  Therefore,  this  method  also  is  not 
adapted  to  give  reliable  data  concerning  the  digestive  activity  of 
the  stomach. 

The  gastric  glands  secrete  not  alone  pepsin  but  also  rennet 
{Labferment),  which  causes  the  coagulation  of  milk.  Its  presence 
may  be  detected  by  taking  a  small  quantity,  10  c.  c.  [f  3  ijss.],  of 
boiled  milk  having  a  neutral  reaction,  and  adding  an  equal  amount 
of  carefully  neutralized  filtered  stomach- contents  ;  the  mixture  is 
then  placed  in  an  incubator  at  100°  Fahr.,  and,  after  a  short  time, 
10  to  15  minutes  on  an  average,  the  milk  has  coagulated  and  sepa- 
rated into  a  cake  of  casein  and  clear  serum.  [Leo  X  ^^ses  10  c.  c.  of 
raw  milk,  and  only  2  to  5  drops  of  stomach-contents.  On  account 
of  the  relatively  small  quantity  of  the  latter,  neutralization  of  the 
mixture  is  unnecessary.     Eaw  milk  is  used  because  it  coagulates 


*  Gunzbui-g.  Ein  Ersatz  der  cliagnostischen  Mageiiaushebermmg.  Deutsch.  med. 
Wochenschr.,  1889,  No,  41. 

f  Sahli,  Ueber  eine  neue  Untersuchimgsmethode  der  Verdauungsorgane  iind 
einige  Resultate  derselben.  Correspondenzblatt  der  schweizer  Aerzte,  1889,  p.  402, 
and  1891,  p.  136. 

X  [Leo.  Diagnostik,  etc.,  1890,  p.  119.  For  quantitative  tests  for  rennet,  and 
also  literature  on  this  subject,  see  Boas,  loc.  ciL,  pp.  26  and  164.— Tr.] 


RENNET.  49 

ten  times  more  rapidly  than  cooked  milk.  "Witli  this  modification 
it  occurs  from  one  minute  to  several  hours  after  being  placed  in 
the  warm  chamber.  The  coagulation  by  rennet  is  the  character- 
istic cake  of  casein  floating  in  clear  serum,  and  is  not  to  be  con- 
founded with  the  flaky  or  lumpy  coagulation  by  acids.] 

The  rennet  ferment  or  enzyme  {Ldbenzym)  exists  also  in  a  pre- 
liminary stage  as  a  pro-enzyme  or  rennet  zymogen  {Lcibzymogen) ; 
this  itself  has  no  action  upon  milk,  but  by  adding  acids,  especially 
hydrochloric  acid,  and  also  calcium  chloride  while  warm,  it  is 
converted  into  the  typical  ferment.  This  will  become  evident  in 
the  filtrate  of  a  gastric  juice  which  either  has  no  spontaneous  coag- 
ulating action  or  in  which  the  ferment  has  been  destroyed  by  add- 
ing an  alkaline  carbonate.  If  this  filtrate  be  digested  with  dilute 
hydrochloric  acid,  or  if  a  5-per-cent  calcium-chloride  solution  be 
added,  it  will  curdle  milk.  In  the  stomach,  while  fasting,  and  at 
the  beginning  of  digestion,  the  zymogen  is  only  found,  but  later 
both  it  and  the  ferment  are  present.  An  acid  reaction  or  the  pres- 
ence of  free  acid  in  the  original  filtrate  of  the  stomach-contents  is 
not  absolutely  necessary  for  the  curdling  action  of  rennet,  since  it 
has  been  demonstrated  Avhen  free  acid  was  absent,  or  even  when 
the  reaction  was  neutral. 

Among  the  various  investigations  on  rennet  in  human  beings 
I  would  call  especial  attention  to  the  works  of  Eaudnitz,  Boas, 
Johnson,  Klemj)erer,  and  C.  Rosenthal.* 

Digestion  of  Starch,  and  Sugar. — You  will  remember  that  in 
the  organism  starch  is  converted  into  grape  sugar  (dextrose) 
by  the  action  of  the  salivary  ferment,  ptyalin,  and  that  cane 
sugar,  as  shown  by  Leube,  is  changed  into  invert-sugar,  a  mixt- 
ure  of    cane   and  grape   sugar.     We   know   that   this   sugar   fer- 

*  Eaudnitz.  Ueber  das  Vorkommen  des  Labferments  ira  Sauglingsmagen. 
Prager  med.  Wochenschr.,  1887,  No.  24. — Boas.  Labferment  und  Labzymogen  im 
gesunden  und  kranken  Magen.  Zeitsehr.  fiir  klin.  Med.,  Bd.  14,  S.  249. — Johnson. 
Studien  iiber  das  Vorkommen  des  Labferments,  etc.  Ibid.,'  S.  240. — Klemperer. 
Die  diagnostischer  Verwerthbarkeit  des  Labferments.  Ibid.,  S.  280. — C.  Rosenthal. 
Ueber  das  Labferment  nebst  Bemerkungen  iiber  die  Production  freier  Salzsaure  bei 
Phthisikern.  Berl.  klin.  Wochenschr.,  1888,  No.  45.  [The  result  of  these  investi- 
gations is  that  rennet,  like  pepsin,  is  a  constant  constituent  of  the  gastric  juice ;  its 
absence  indicates  atrophy  of  the  gastric  mucosa  ;  otherwise  it  has  no  practical  sig- 
nificance. Leo,  Joe.  cit.,  p.  120. — Tr.] 
4 


50  DISEASES   OF   THE  STOMACH. 

ment  exists  not  alone  in  the  saliva,  but  also  in  small  quantities 
in  very  many  tissues,  and  probal)ly  also  in  the  mucus  which 
is  usually  sparingly  secreted  in  the  stomach.  It  was  formerly 
supposed  that  ptyaliu  acted  on  the  amylaceous  substances  only  in 
the  mouth  during  mastication.  At  all  events,  the  transformation  of 
starch  into  sugar  by  ptyalin  occurs  very  rapidly  indeed ;  yet  this 
would  not  suffice  to  allow  the  ferment  to  act  thoroughly  on  the 
more  or  less  compact  masses  swallowed.  The  saliva  which  is  swal- 
lowed continues  its  action  on  the  amylaceous  substances  even  in  the 
stomach,  as  has  been  shown  by  von  den  Yelden.*  The  only  ques- 
tion is.  How  long  does  this  process  continue  ?  We  know  that 
pytalin  acts  best  in  neutral  or  feebly  alkaline  solutions,  but  is 
checked  in  acid  fluids.  It  has  been  shown  that  the  formation  of 
sugar  ceases  as  soon  as  the  amount  of  acid  (reckoned  for  hydro- 
chloric acid — a  point  of  vital  importance  to  us)  reaches  O'Ol  per 
cent  or  more ;  but  in  smaller  quantities  the  action  of  the  ferment 
is  even  somewhat  accelerated  (Chittenden),  With  lactic  acid  the 
acidity  must  be  much  higher,  namely,  0*1  to  0*2  per  cent,  and  with 
butyric  acid  or  fatty  acids  may  be  even  higher  than  this,  up  to  0"4 
per  cent.  But,  as  first  shown  in  pigs  and  horses  by  Ellenberger 
and  ITofmeister,f  and  in  human  beings  by  Ewald  and  Boas,  the 
simple  taking  of  raw  starch  will  cause  the  secretion  of  hydro, 
chloric  acid,  to  which  is  later  added  the  lactic  acid  produced  by 
fermentation.  This  naturally  occurs  also  in  a  mixed  diet  with 
amylaceous  substances.  As  normally  the  acidity  of  the  stomach- 
contents  gradually  becomes  more  marked  as  more  hydrochloric  acid 
is  secreted,  we  will  hence  observe  an  initial  stage  in  which  starch 
is  still  converted  into  sugar ;  but  gradually  the  process  becomes 
feebler,  and  finally  ceases  entirely.  Thus  the  conversion  of  starch 
into  sugar  is  not  a  simple  uniform  process,  but,  like  the  digestion  of 
albumen,  there  are  intermediate  products,  the  dextrins  and  maltose.:}: 

*  R.  V.  d.  Velden.  Ueber  die  Wirksamkeit  des  Mundspeichels  im  Magen. 
Deutsch.  Arch,  fiir  klin.  Med.     Bd.  25,  S.  105. 

f  Ellenberger  undHofmeister.  Arch,  fiir  wissensch.  und  prakt.  Thierheilkunde, 
viii,  S.  395,  and  xii,  S.  126.— Pfliiger's  Archiv,  Bd.  44,  S,  484. 

X  See  Ewald.  Klinik,  etc.,  1.  Theil,  3  te  Auflage,  S.  55  et  seq.  Also  a  detailed 
account  in  Ewald  :  Ueber  die  Zuckerbildung  im  Magen  und  Dyspepsia  acida.  Berl. 
klin.  Wochenschr.,  188G,  No.  48. 


DIGESTION  OF  STARCH  AND  SUGAR.  51 

The  two  important  varieties  of  dextrin  are  erythrodextrin  and 
acliroodextrin.  Maltose  is  to  a  certain  extent  an  intermediate  body 
between  starcli  and  dextrin  on  tlie  one  band,  and  grape  sugar  on 
tbe  other. 

Starch  is  recognized  by  the  familiar  deep-blue  color  struck  with 
iodine  or  a  mixture  of  iodine  and  potassium  iodide — i,  e.,  Lugol's 
solution  : 

lodi O'l  [gr.  jss.] 

Potass,  iodidi 0'2  [gr.  iij] 

Aq.  destillat 200-0  [f  I  vj  3  vj] 

This  reaction  becomes  less  marked  in  proportion  to  the  amount 
of  starch  converted  into  dextrin  and  sugar.  A  solution  of  ery- 
throdextrin, as  its  name  indicates,  no  longer  gives  a  blue  color,  but 
purple ;  solutions  of  acliroodextrin,  maltose,  or  dextrose  assume  no 
other  color  than  the  yellow  of  the  iodine  solution.  The  latter 
substances  have  a  closer  relation  to  iodine  than  dextrin,  and  the 
latter  again  more  than  starch  ;  hence,  in  a  mixture  of  these  bodies, 
the  first  drops  of  iodine  solution  added  cause  either  no  color  at  all 
or  only  a  transitory  one,  and  it  is  only  after  adding  more  iodine 
that  the  purple  of  erythrodextrin  or  the  blue  tinge  of  starch  is 
observed. 

As  was  shown  by  von  Mering  in  laboratory  experiments,  and 
by  myself  on  human  beings,  in  the  transformation  of  starch  into 
sugar  by  ptyalin,  the  smaller  portion  only  is  converted  into  dex- 
trose, the  greater  into  maltose.  The  latter  passes  on  into  the  intes- 
tines, where  it  is  changed  into  dextrose  (Brown  and  Heron). 

The  practical  result  of  these  conditions  is  the  following  :  If  the 
amylaceous  transformation  proceeds  normally  in  the  mouth  and 
stomach,  after  a  time,  within  an  hour  at  least,  so  much  starch  has 
been  changed  into  achroodextrin,  maltose,  or  dextrose  that  the  ad- 
dition of  small  quantities  of  Lugol's  solution  to  the  filtered  stomach- 
contents  no  longer  produces  any  changes  of  color.  The  occurrence 
of  a  purple  (erythrodextrin)  or  a  blue  color  (starch)  shows  that  the 
sugar  transformation  has  been  incomplete.  This  may  be  due  either 
to  a  deficiency  of  ptyalin  or  to  a  too  rapidly  increasing  acidity  or 
an  original  hyperacidity  of  the  stomach. 

If,  then,  we  should  be  unable  to  titrate  the  gastric  contents — 
5 


52  DISEASES  OF  THE  STOMACH. 

supposing,  for  example,  that  we  had  only  a  very  small  quantity — 
such  a  result  would  of  itself  indicate  a  hyperacidity  of  the  gastric 
juice.  But  under  such  circumstances  we  might  also  suspect  a  de- 
ficiency of  ptyalin  in  the  saliva,  and  hence  a  normal  acidity  of  the 
stomach.  Yet  this  does  not  appear  to  be  the  case.  For  a  long 
time  I  have  tested  the  fermentative  power  of  saliva  in  patients 
with  dental  caries,  inflammatory  lesions  in  the  mouth,  angina,  diph- 
theria, carcinoma  of  the  tongue,  and  similar  conditions,  but  never 
have  I  found  a  saliva  which  could  not  convert  starch  into  sugar  ; 
yet  I  must  not  fail  to  add  that  no  quantitative  examinations  were 
made.  It  appears  that  saliva  does  not  lose  any  of  its  ferment,  but 
pepsin  seems  now  and  then,  although  very  rarely,  to  be  absent 
from  the  gastric  juice.  Sugar  may  always  be  found  in  the  stom- 
ach-contents after  the  test-breakfast,  since  a  certain  amount  is  con- 
tained in  it. 

There  are  still  two  factors  to  be  discussed — the  dbsorptive  power 
of  the  stomach  and  its  'motor  functions — two  points  which  have 
recently  been  underestimated  because  they  have  been  overshadowed 
by  purely  chemical  examinations. 

Absorption  by  the  gastric  mucous  membrane  is  tested  with  potas- 
sium iodide.  Penzoldt*  recommends  giving  it  in  small  doses  of 
O'l  gramme  [gr.  jss.]  in  capsules  which  have  been  carefully  wiped  oif , 
so  that  none  of  the  drug  adheres  to  the  outside  of  the  capsule.  A 
capsule  is  taken,  and  the  moment  iodine  appears  in  the  saliva  is 
determined  by  means  of  the  well-known  reaction  with  starch  paste. 
Filter-paper  is  moistened  with  starch  paste  and  dried  ;  after  the  cap- 
sule is  taken,  from  time  to  time,  say  every  five  minutes,  a  little  of 
the  patient's  saliva  is  placed  upon  the  dried  filter-paper.  Then  by 
adding  some  fuming  nitric  acid  (one  or  two  drops)  the  appearance 
of  a  blue  color  will  indicate  exactly  when  the  iodine  appears  in  the 
saliva.  I^ormally  this  occurs  in  ten  to  fifteen  minutes  ;  but  in 
processes  where  absorption  by  the  stomach  is  slow  or  fails  entirely, 
this  reaction  occurs  much  later,  being  delayed  a  half  to  a  whole 
hour  or  even  longer.     At  my  request.  Dr.  Boas  investigated  this 


*  Penzoldt  und  Faber.     Resorptionfahigkeit  des   menschlichen  Magens.     Berl. 
klin.  Wochenschr.,  1882,  No.  21. 


MOTILITY  OP  STOMACH.  53 

subject ;  his  results,  as  well  as  those  of  many  others  and  myself, 
agree  in  confirming  them,  and  I  must  therefore  contradict  the 
statements  of  J.  Wolff",  and  regard  periods  of  absorption  of  one  to 
one  and  a  half  hours  as  decidedly  pathological.  Consequently,  this 
procedure  offers  us  a  simple  means  of  determining  the  absorptive 
powers  of  the  stomach.     [See  also  p.  48.] 

Another  question  is.  How  can  we  test  the  motility  or  motor 
function  of  the  stomach?  The  determination  of  the  normal  peri- 
stalsis and  proper  movement  of  the  ingesta  in  and  expulsion  out 
of  the  stomach  is  very  important ;  for  a  number  of  observations 
which  have  recently  accumulated  indicate  more  and  more  that  a 
stomach  whose  chemical  functions  are  more  or  less  altered  may 
nevertheless — I  will  not  say  completely,  but  almost  so — fulfill  its 
digestive  duties,  so  that  this  deficiency  in  the  chemical  processes  may 
be  compensated  by  the  motor  function,  and  hence  may  effect  the 
expulsion  of  the  chyme  from  the  stomach  at  the  proper  time. 

I  have  had  under  my  observation  for  three  years  a  foreign  gen- 
tleman whose  stomach  -  contents  I  have  examined  several  times 
yearly,  and  yet  have  never  been  able  to  detect  free  hydrochloric 
acid  and  pepsin.  He  goes  to  Kissingen  every  summer,  feels  toler- 
ably well,  eats  large  dinners,  pursues  his  occupation ;  and  yet  I 
must  confess  that  without  exception  hydrochloric  acid  and  pepsin 
-have  been  absent  in  every  test  made  at  various  intervals  after  eating 
different  kinds  of  food,  both  the  test-breakfast  as  well  as  larger 
meals.  Dr.  L.  Wolff  and  myself  *  have  published  analogous  cases, 
and  recently  I  have  had  a  similar  experience  in  a  female  patient 
upon  whom  gastrotomy  was  performed  for  carcinoma  of  the  oesoph- 
agus. From  this  we  may  infer  that  under  certain  circumstances  the 
secretory  function  of  the  stomach  is  not  essential  to  maintain  life 
providing  that  the  lesion  in  the  stomach  does  not  of  itself  imperil 
life  by  a  general  intoxication,  but  that  under  these  conditions  the 
intestinal  digestion  seems  to  vicariously  assume  the  entire  burden. 
This  is  plausible,  since  the  chemical  processes  of  digestion  are 
doubly  provided  for :  two  secretions  digest  starch — i.  e.,  saliva  and 

*  L.  Wolff  undEwald.  Ueber  das  Fehlen  der  freien  Salzsaure  ira  Mageninhalt. 
Berl.  klin.  Wochenschr.,  1887,  No.  30;  and  Ewald,  ibid.,  1887,  No.  49,  Verhand- 
lunsren  des  Vereins  fiir  innere  Mediein. 


54  DISEASES  OP  THE  STOMACH. 

tlie  pancreatic  juice ;  albumen  may  be  peptonized  at  two  places, 
the  stomach  and  intestines  ;  and  fats  may  be  emulsified  by  the  pan- 
creatic juice  and  bile.  The  intestine  is  thus  capable  of  acting 
vicariously  for  the  stomach,  if  necessary.  Similar  conclusions  have 
been  reached  by  other  writers.  But  Jaworski  has  gone  to  extremes 
in  maintaining  that  the  chemical  functions  of  the  stomach  play  a 
subordinate  part,  and  that  the  stomach  is  nothing  more  than  a  store- 
room and  warming-place  where  the  food  may  enter  and  be  admitted 
to  the  intestine  as  through  a  sluice.  This  is  a  wild  speculation, 
which  brings  us  back  to  the  old  Hippocratic  doctrine  of  the  coctio 
cihorum,  the  cooking  of  the  food  by  the  animal  heat. 

Salol  Test. — Up  to  recent  times  we  had  no  suitable  method  for  de- 
termining the  motor  function  of  the  stomach.  Leube's  proposition 
to  estimate  the  duration  of  digestion — i.  e.,  to  determine  after  a  defi- 
nite average  time  of  six  to  seven  hours  after  a  large  meal,  or  two  to 
two  and  a  half  hours  after  Ewald's  test-breakfast,  whether  solid  con- 
tents were  still  to  be  found  in  the  stomach — is  subject  to  too  many 
physiological  variations  to  permit  any  reliable  deductions.  And  the 
great  practical  objection  is  that  it  requires  the  use  of  the  stomach- 
tube.  Absorption  as  well  as  motion  is  involved.  For  the  separate 
determination  of  the  latter  I  have  proposed  the  use  of  salol.*  Salol 
is  a  compound  of  phenol  and  salicylic  acid — a  phenol  ether  of 
salicylic  acid  which,  according  to  Nencki,  is  not  changed  by  acids 
but  is  converted  by  the  action  of  the  pancreas  into  salicylic  acid  and 
phenol.  Supposing  this  to  be  true,  salol  would  be  a  splendid  means 
of  determining  not  alone  how  rapidly  substances  pass  from  the 
stomach  into  the  intestine,  but  also  whether  the  action  of  the  pan- 
creas is  normal — a  subject  which  is  still  enveloped  in  darkness. 
With  these  premises.  Dr.  Sievers,  of  Helsingfors,  and  myself  under- 
took a  series  of  observations  which  showed  that  salol  is  decomposed  by 
relatively  feeble  alkaline  fluids,  but  that  it  is  not  decomposed  wdien 
introduced  into  the  stomach  or  when  mixed  outside  of  this  viscus 
with  acid  stomach-contents  or  artificial  digestive  mixtures  with 
pepsin   and   hydrochloric   acid.      The   splitting    up   of    salol    into 


*  Sievers  und  Ewald.     Zur  Pathologie  und  Therapie  der  Magenectasien.     The- 
rapeutische  Monatshefte,  August,  1887. 


SALOL  TEST.  55 

salicylic  acid  and  plienol,  and  the  appearance  in  the  urine  of  sali- 
cyluric acid,  the  product  of  the  decomposition  of  salicylic  acid,  will 
indicate  that  the  salol  has  actually  passed  out  of  the  stomach. 

formally,  salicyluric  acid  will  appear  in  the  urine,  40  to  60,  at 
most  Y5  minutes  after  taking  one  gramme  [gr.  xv]  of  salol,  which 
has  been  given  preferably  during  the  course  of  digestion.  Hence 
delay  in  its  appearance  will  indicate  a  retardation  in  the  passage  of 
food  into  the  intestines.  Salol  is  a  white,  tasteless  powder  which 
is  easily  administered  ;  it  is  given  in  capsules ;  gelatin-coated  pills 
might  also  be  used,  but  these  sometimes  pass  unchanged  through 
the  intestines,  and  pills  may  easily  remain  an  abnormally  long  time, 
or  at  least  for  varying  periods,  in  the  folds  of  the  gastric  mucous 
membrane.  The  great  advantage  of  salol  resides  in  the  fact  that  it 
is  thoroughly  mingled  with  the  stomach-contents  and  certainly  par- 
ticipates in  their  movements.  Salicyluric  acid  is  easily  recognized 
in  the  urine  by  the  violet  color  produced  on  the  addition  of 
neutral  ferric  chloride  solution.  To  detect  the  earliest  trace  of  it, 
acidulate  the  urine  with  hydrochloric  acid  and  extract  with  ether ; 
the  salicyluric  acid  combines  with  the  ether,  and  may  be  easily  de- 
tected in  the  ethereal  extract.  A  simple  method  is  to  place  a  drop 
of  urine  on  a  piece  of  filter-paper,  and  then  let  a  drop  of  a  10-per- 
cent ferric-chloride  solution  fall  upon  the  moistened  spot  on  the 
filter-paper.  The  edge  of  the  drop  will  assume  a  violet  color  in  the 
presence  of  even  the  smallest  trace  of  salicyluric  acid.  These  pa- 
pers may  be  dried  and  preserved,  and  in  this  way  one  may  easily 
compare  the  reaction  in  the  same  patient  at  various  times. 

Unfortunately,  in  this  method  the  time  of  the  decomposition  of 
the  salol  depends  on  the  occurrence  of  the  neutral  or  alkaline  reac- 
tion of  the  intestine ;  even  under  normal  conditions  this  may  vary, 
since  i|;  depends  on  the  changeable  reaction  of  the  chyme  and  the 
quantity  of  bile  and  pancreatic  juice  which  reaches  the  intestines. 
We  (Sievers  and  Ewald)  thought  that  we  could  exclude  this  source 
of  error  by  having  empirically  calculated  the  above  average  length 
of  time  ;  and,  in  fact,  in  the  great  majority  of  our  experiments  this 
period,  60  to  75  minutes  after  taking  the  salol  to  the  beginning  of 
this  reaction  in  the  urine,  proved  to  be  constant.  But  this  con- 
stancy has  been  questioned  by  other  observers.     For  this  reason 


56  DISEASES  OF   THE  STOMACH. 

Huber*  has  estimated  the  time  wliich  elapses  from  the  taking  of 
the  salol  to  the  complete  disa23pearance  of  the  reaction  in  the  urine. 
In  healthy  persons  this  excretion  lasts  24  hours ;  in  patients  with 
enfeeblement  of  the  motor  functions  of  the  stomach  it  lasted  48 
hours,  or  even  longer.  Yet  even  here  it  is  impossible  to  definitely 
ascertain  how  much  of  this  time  is  due  to  tardy  movements  of  the 
stomach,  and  how  much  to  delayed  intestinal  absorption.  How- 
ever, Silberstein,f  unlike  Pal  and  Decker,+  has  obtained  favorable 
results  with  this  method ;  in  26  cases  of  gastric  dilatation  and  in 
12  cases  of  atony  of  the  muscular  fibers  of  the  stomach  the  excretion 
of  salicyluric  acid  lasted  till  the  second  day — i.  e.,  30  hours  or  more. 
The  condition  of  the  bowels,  diarrhoea  or  constij)ation,  appeared  to 
exert  no  influence,  although  a  py^iori  this  would  seem  to  be  very 
improbable ;  for  in  diarrhoea  the  intestinal  contents  are  certainly 
evacuated  more  rajjidly ;  hence  the  salol  passes  through  the  intes- 
tines much  more  rapidly  than  under  normal  conditions.  To  carry 
out  Huber's  test,  one  gramme  [gr.  xv]  of  salol  is  given,  and  the 
urine  is  examined  24  to  30  hours  later.  If  salicyluric  acid  is  still 
present  at  the  latter  period,  or  even  later,  we  may  with  tolerable  cer- 
tainty infer  a  disturbance  of  the  muscular  activity  of  the  stomach.* 
An  objection  was  raised  that  although  the  salol  might  not  have 
been  decomposed  in  the  stomach,  yet  it  could  have  been  absorbed 
as  such,  enter  the  blood,  and  be  altered  there  and  then  be  excreted. 
This  argument  has  been  disproved  by  the  following  experiment  : 
We  took  a  dog,  placed  double  ligatures  about  the  pylorus,  and  then 
gave  the  animal  some  salol ;  three  hours  later  the  dog  was  killed, 
and  up  to  that  time  not  a  trace  of  salicylic  or  salicyluric  acid  could 
be  detected  in  the  urine.  This  is  an  absolute  proof  that  salol  is 
not  absorbed  by  the  stomach. 

*  A.  Huber.  Zur  Bestimraung  der  motorischen  Thatigkeit  des  Magens.  Munch, 
med.  Wochenschr.,  1887,  No.  19. 

f  Silberstein.     Deutsch.  med.  Wochenschrift,  1891,  No.  9. 

X  Pal.  Ueber  die  Verwerthung  der  Salolspaltung  zu  diagnostischen  Zweeken. 
Wiener  klin.  Wochenschr..  1889,  No.  48. — Decker.  Zur  Prage  des  diagnostischen 
Werthes  des  Salol s  bei  motorischen  Insufficienz  des  Magens.  Berl.  klin.  Wochen- 
schrift, 1889,  No.  45. 

*  [Recently  a  death  has  been  reported  from  the  use  of  this  method.  See  Lon- 
don Lancet,  May  23,  1891.  Such  an  accident  must  be  regarded  as  a  very  rare 
event. — Tr.] 


OIL   TEST.— BILE.  57 

Oil  Test. — Klemperer  *  lias  proposed  another  method  for  deter- 
mining the  motor  activity  of  the  stomach.  He  pours  a  definite  quan- 
tity, 100  c.  c.  [f  ^iij  3ij],  of  pure  ohve  oil  into  the  empty  stomach 
which  has  previously  been  washed  out,  if  necessary  ;  two  hours  later 
the  stomach  is  aspirated,  and  whatever  oil  is  left  is  removed  as 
thoroughly  as  possible,  till  only  an  insignificant  trace  remains.  The 
difference  between  the  original  quantity  of  oil  and  that  aspirated 
is  used  by  him  as  an  indication  of  the  motor  function  of  the  stom- 
ach. However,  even  Klemperer  himself  admits  that  this  method 
can' not  be  always  used  in  general  practice,  because  it  is  complicated 
and  objectionable  to  patients.  He  simply  proposes  to  use  it  to 
discover  certain  typical  forms  of  motor  insufficiency  which  are  of 
themselves  so  characteristic  that,  having  once  demonstrated  them 
by  the  oil  method,  its  further  use  would  be  unnecessary.  The  fu- 
ture will  show  how  far  this  object  will  have  been  accomplished  ;  at  all 
events,  his  results  thus  far  concerning  the  influence  of  certain  drugs 
upon  the  movements  of  the  stomach  agree  very  well  with  the  con- 
clusions arrived  at  with  the  salol  method. 

Finally,  I  must  state  that  bile  may  be  detected  in  the  contents 
of  the  stomach  by  the  greenish  tinge  it  imparts,  or  by  Gmelin's 
test.  It  is  also  characteristic  of  biliary  pigment  that  the  bright 
yellow  debris  left  upon  the  filter  upon  filtering  the  stomach-contents 
after  the  test-breakfast,  and  especially  that  portion  at  the  edge  of 
the  filter,  assumes  a  greenish  tinge  by  oxidation  after  prolonged 
exposure  to  the  air. 

This  concludes  the  various  chemical  methods  of  examination  of 
the  diseased  stomach.  Their  significance  in  the  diagnosis  and  treat- 
ment of  the  diseases  of  the  stomach  will  be  distinctly  stated  on  all 
occasions  in  the  following  discussions.  As  far  as  I  am  free  from 
an  overestimation  of  these  methods,  as  you  have  already  observed 
in  my  opening  remarks,  so  sure,  nevertheless,  am  I  that  in  the 
future  we  may  confidently  expect  many  valuable  additions  to  our 
stock  of  knowledge  from  the  field  of  investigation  just  inaugu- 
rated. 


*  Klemperer.     Ueber   die    motorische    Thatigkeit   des    menschlichen    Magens. 
Deutsche  med.  Wochenschr.,  1887,  No.  47. 


58  DISEASES  OF  THE  STOMACH. 

The  physical  methods  of  examination,  the  second  great  group  of 
our  diagnostic  aids,  I  can  only  speak  of  here  in  so  far  as  they  have 
a  direct  bearing  upon  the  examination  of  the  stomach,  or  are  con- 
nected with  it  in  some  peculiar  manner.  Moreover,  in  the  descrip- 
tion of  the  various  diseases,  I  shall  have  many  opportunities  to 
speak  of  percussion,  auscultation,  inspection,  etc.,  so  that  I  shall 
now  restrict  myself  to  the  following  technical  factors  or  aids.  [See 
pages  172  et  seq?^ 

1.  Palpation. — Of  all  the  various  means  of  examining  the  ab- 
dominal organs  this  is  undoubtedly  the  most  important.  Whoever 
can  palpate  well,  and  has  a  delicate  sense  of  touch,  possesses  an 
advantage  in  diagnosis  which  is  not  to  be  overestimated.  Natu- 
rally there  must  always  be  a  combination  of  the  tactile  impression 
and  the  mental  process  which  will  enable  the  observer  at  that  par- 
ticular moment  to  draw  upon  the  whole  range  of  his  experience  and 
to  use  it  upon  the  case  in  question ;  or,  to  use  a  figure  of  speech, 
which  will  enable  him  to  look  through  the  abdominal  walls  and 
direct  his  fingers.  For  exam23le,  the  great  clinician  von  Frerichs, 
who  possessed  a  marvelous  certainty  and  skillfulness  in  palpation, 
was  certainly  greatly  aided  by  this.  But  a  proper  technique  is 
very  important  here,  and,  as  I  so  often  see  erroi'S  committed  and 
examinations  rendered  difficult  and  uncertain,  I  shall  be  pardoned 
if  I  call  attention  to  several  very  well  known  points :  Never  pal- 
pate with  the  hand  held  perpendicularly  or  obliquely  to  the  abdomi- 
nal wall ;  gradually  and  carefully  go  deeper  by  small  rotatory 
movements  in  a  horizontal  plane.  Place  your  hands  flat  upon  the 
abdomen,  and  only  press  down  gradually  and  with  very  gentle 
pressure  by  bending  the  end  phalanges.  In  this  way  we  not  alone 
prevent  the  contraction  of  the  abdominal  muscles  whose  edges  have 
caused  errors  and  uncertainty  in  even  very  experienced  clinicians, 
but  we  also  obtain  a  much  better  perception  of  the  site,  size,  and 
form  of  any  peculiar  conditions  beneath  the  abdominal  wall ;  and, 
finally,  last  but  not  least,  we  cause  a  minimum  of  discomfort  and 
pain  to  the  patient.  Here  the  same  considerations  are  true  as  in 
percussion.  As  is  well  known,  differences  of  tone  which  are  per- 
ceptible with  gentle  percussion  are  overlooked  when  it  is  forcible. 
It  is  hardly  necessary  to  state  that  under  certain  circumstances  firmer 


DISTENTION  OF   STOMACH   WITH   AIR.  59 

pressure  may  be  needed  in  jDalpation,  and  a  stronger  stroke  may  be 
required  in  percussion,  yet  such  cases  always  have  pecuHar  features 
wliich  distinguish  them  from  the  ordinary  ones.  Sometimes  it  may 
be  of  great  advantage  to  supplement  the  palpation  in  the  dorsal 
and  lateral  posture  by  examining  the  patient  in  the  knee-elbow 
position.  Movable  tumors  will  then  sink  against  the  anterior  ab- 
dominal wall,  and  may  be  recognized  as  such. 

2.  Distention  of  the  Stomach  and  Intestines  with  Air.  —  The 
method  of  distending  the  stomach  with  carbonic-acid  gas  generated 
in  loco  was  introduced  by  von  Frerichs,  and  since  then  has  been 
in  general  use.  Yon  Ziemssen,*  following  the  American  method, 
applied  it  also  to  the  intestines  by  administering  per  rectum  bi- 
carbonate of  soda  and  some  organic  acid  ;  we  may  also  employ 
carbonic  -  acid  gas  already  generated  outside  of  the  body — for  ex- 
ample, from  an  inverted  siphon  of  mineral  water  (Schnetter).f 
These  methods  suffer  from  the  disadvantages  that  we  have  no  con- 
trol over  the  amount  of  gas  produced  after  the  salts  have  been 
introduced  into  the  stomach  or  intestines,  that  disagreeable  ac- 
companying symptoms  frequently  arise  from  the  irritation  of  the 
carbonic-acid  gas  upon  the  walls  of  the  stomach  or  intestines,  and 
that,  even  though  varying  quantities  of  gas  are  needed  for  different 
persons,  the  degree  of  tension  produced  can  not  be  regulated  at 
will  nor  increased  at  a  given  moment.  For  these  reasons  it  is 
better  to  use  the  method  recently  recommended  by  Runeberg,;}: 
which  has  long  been  used  by  Oser*  and  myself,  and  which  con- 
sists in  introducing  a  stomach  or  rectal  tube,  and  then  insufflating 
air  with  the  double  bulbs  of  a  spray  apparatus.  Frequently  there 
are  also  other  good  reasons  for  introducing  the  tube  in  a  given  case, 
and  this  does  away  with  any  objections  against  a  special  passage  of  the 
tube  with  its  accompanying  inconveniences,  although  the  latter  are 
really  too  insigniiicant  to  have   any  weight.     Runeberg  says  cor- 

*  V.  Ziemssen.  Die  kiinstliche  Gasaufblahung  des  Dickdarms  zu  diagnostisehen 
und  therapeutischen  Zweeken.     Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  33,  S.  235. 

f  Schnetter.  Zur  Behandlung  der  Darmverschliessungen.  Deutsch.  Arch,  fiir 
klin.  Med.  Bd..  34,  S.  638. 

X  "W.  Runeberg.  Ueber  kiinstliche  Aufblahung  des  Magens  und  des  Dickdarms^ 
durch  Einpumpen  von  Luft.     Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  34,  S.  460. 

*  Oser.     Die  Neurosen  des  Magens.     Wien,  1885,  S.  10. 


60  DISEASES  OP  THE  STOMACH. 

rectly  :  "  In  endeavoring,  for  example,  to  estimate  exactly  tlie  size 
and  situation  of  a  markedly  dilated  stomacli  it  is  by  no  means  an 
easy  task  to  obtain  a  suitable  degree  of  distention  by  generating 
carbonic-acid  gas.  On  the  other  hand,  this  may  be  very  conven- 
iently and  easily  accomplished  by  this  method  of  pumping  in  air." 
The  same  is  true  of  the  intestines,  especially  of  the  transverse 
colon.  Any  excess  of  air  pumped  in  escapes  alongside  of  the  tube, 
or  is  easily  expelled  by  a  reactive  contraction  of  the  stomach  as  soon 
as  the  patient  experiences  a  marked  tension  of  that  viscus.  In 
using  carbonic-acid  gas  the  reverse  usually  occurs,  since  the  irrita- 
tion of  the  gas  causes  a  spasmodic  contraction  of  the  cardia,  so  that 
the  patient  must  exert  himself  more  vigorously  to  expel  it ;  fur- 
thermore, the  pylorus  may  relax  more  readily  than  the  cardia,  and 
the  gas  may  then  pass  on  into  the  small  intestines.  I  have  never 
observed  the  condition  described  by  Ebstein  as  insufficiency  of  the 
pylorus,  in  which  the  gas  generated  in  the  stomach  passes  rapidly 
into  the  duodenum  ;  I  believe  that  conditions  in  which  the  pylorus 
is  not  relaxed  at  first,  but  only  during  the  generation  of  the  carbonic- 
acid  gas,  are  due  to  the  causes  above  mentioned.  It  is  true  Schiitz  * 
has  had  just  the  reverse  experience  of  observing  the  air  pumped 
in  escape  rapidly  into  the  intestine,  but  it  seems  to  me  that  this 
was  an  exceptional  case,  which  does  not  agree  with  the  experiences 
of  Oser  f  and  of  myself.  Insufflation  of  the  stomach  and  intestines 
may  be  combined.  Recently  Behrens  :|:  called  attention  to  the  value 
of  the  latter  method  for  detecting  tumors  which  might  be  present 
in  the  abdominal  cavity.  According  to  my  own  experience,  the 
quantity  of  air  to  be  pumped  in  through  the  rectum  is  very  varia- 
ble, and  the  same  is  true  of  the  distinctness  with  which  the  dis- 
tended coils  of  intestines  may  be  seen.  I  have  always  been  struck 
by  the  amount  of  air  which  could  be  pumped  in  through  the  anus 
without  again  escaping,  providing,  of  course,  that  there  is  no  marked 
accumulation  of  fseces.     Where  the  latter  exists,  and  in  strictures 

*  E.  Schiitz.     Wanderniere  iind  Magenerweiterung.     Prag.  med.  Wochenschr., 
January  14,  1885. 

f  Oser.    Die  Ursachen  der  Magenerweiterung.     Wiener  med.  Klinik,  1881,  S.  4. 
(,       X  0.  Behrens.     Ueber  den  Werth  der  kiinstlichen  Auftreibung  des  Dickdarms 
\  nit  Gasen  und  mit  Fllissigkeiten.     Gottingener  Inaugural  Dissertation.     Helm- 
siaJ^-it,  1886. 


THE  DEGLUTITION-MURMURS.  61 

and  stenoses  of  the  lower  portion  of  the  intestine,  the  air  is  soon 
expelled,  together  with  foul-smelling  gases.  This  feature  was  strik- 
ingly illustrated  in  a  recent  case  of  compression  of  the  descending 
colon  by  a  neoplasm. 

3.  Distention  of  the  Stomach  with  Water. — A  somewhat  similar 
but  less  convenient  idea  was  embodied  in  the  j)lan  proposed  by 
Piorry,  but  made  especially  well  known  by  Penzoldt*  to  deter- 
mine the  site  of  the  lower  border  of  the  stomach  by  filling  that 
viscus  with  water.  As  water  sinks  to  the  lowest  part  of  the  stom- 
ach, in  a  sitting  or  standing  posture,  a  large  quantity  of  fluid  intro- 
duced into  the  organ  will  indicate  the  course  of  the  greater  curva- 
ture by  a  curved  line  of  dullness  with  the  convexity  downward — 
providing  that  the  transverse  colon  contains  air ;  and  by  pouring 
in  and  siphoning  out  larger  quantities,  about  one  litre  [quart],  we 
will  prevent  mistaking  it  for  neighboring  organs,  tumors,  etc., 
having  a  dull  percussion  note.  Further  details  concerning  this 
method,  and  also  a  modification  proposed  by  Dehio,  will  be  dis- 
cussed while  speaking  of  dilatation  of  the  stomach. 

4.  The  Deglutition  -  murmurs  {SchluchgerdusGhe),  as  diagnostic 
aids.     At  another  place  f  I  have  spoken  of  the  nature  and  character 


*  Penzoldt.     Die  Magenerweiterung.     Brlangen,  1877. 

f  Ewald.  Klinik  der  Verdauungskrankheiten,  I.  Theil,  3te  Auflage,  S.  67  to 
70.  [As  these  murmurs  are  quite  frequently  referred  to  in  the  following  pages,  this 
brief  extract  of  the  author's  views  as  to  their  nature  and  origin  has  been  added.  At 
the  beginning  of  swallowing  a  murmur  is  propagated  from  the  pharynx  into  the 
(Esophagus  ;  this  sound  has  no  significance  whatsoever.  The  true  murmurs  are  the 
Durchspritzgerdusch  and  the  Vurchpressgerdusch.  Ewald  thinks  it  much  better 
to  call  them  simply  the  first  and  second  murmurs  respectively.  The  fir'st  murmur 
(Spritzgerduseh)  occurs  almost  immediately  after  the  beginning  of  deglutition,  and 
is  a  hissing  sound  as  if  the  fluid  were  being  directly  squirted  into  the  stethoscope 
Some  time  after,  usually  six  to  seven  seconds,  the  second  sound  {Pressgerduscli)  is 
heard ;  this  is  a  series  of  tones  rapidly  following  one  another,  either  gurgling,  cluck- 
ing, sprinkling,  or  splashing.  These  murmurs  are  heard  only  near  the  cardia ;  the 
best  site  is  just  below  the  xiphoid  cartilage  ;  this  at  once  distinguishes  them  from  the 
sounds  transmitted  from  the  pharynx,  which  may  be  heard  all  along  the  oesophagus. 
The  first  sound  is  only  heard  rarely  ;  its  occurrence  is  said  to  denote  a  relaxation 
of  the  cardia,  and  the  direct  passage  of  the  food  into  the  stomach ;  the  second  is 
quite  constant,  and  is  absent  only  when  the  first  is  heard.  Its  nature  is  not  so  evi- 
dent :  some  (Kronecker)  claim  that  it  is  due  to  the  audible  vibrations  of  the  cardia 
which  are  caused  by  the  passage  of  the  food  over  it ;  others  (Zencker,  Quincke, 
Ewald,  Dirksen)  assert  that  it  is  simply  a  result  of  the  pressing  through  of  the  air 
which  has  been  swallowed  with  the  food. 


62  DISEASES  OF  THE  STOMACH. 

of  tliese  murmurs,  and  shall  simply  say  here  that  they  give  no 
positive  indications  in  the  diagnosis  of  gastric  diseases.  Meltzer* 
claimed  that  the  so-called  Schluckgerdusch-  wn.^  due  to  a  relaxation 
of  the  cardia,  and  occurred  as  a  specific  symptom  of  old  syphi- 
lis, phthisis  accompanied  by  mild  vomiting,  neuroses  of  the  cardia, 
etc.  The  inconstancy  of  the  phenomenon  was  shown  by  Dirksen  f 
and  myself.  I  have  never  observed  any  constant  and  characteristic 
change  in  the  intensity  or  quality  of  these  murmurs,  either  in  para- 
lytic spinal  lesions  or  dilatation  of  the  stomach,  or  in  any  other 
condition  which  at  first  sight  might  seem  to  include  this  phenome- 
non. On  the  other  hand,  tyjjical  and  of  diagnostic  value  is  the 
absence  of  the  deglutition-murmurs  in  complete  or  almost  complete 
closure  of  the  cardia,  whether  the  obstruction  be  above  or  below 
the  cardia.  Yet  this  negative  proof  must  be  determined  positively 
by  repeated  examinations,  since  the  murmur  is  now  and  then  ab- 
sent in  healthy  persons. 

5.  Another  method  of  examination  requiring  a  few  words  is 
that  inaugurated  chiefly  through  the  labors  of  Mikulicz — gastroscopy, 
or  the  direct  visual  examination  of  the  mucous  membrane  of  the 
stomach  with  a  specially  adapted  instrument,  the  gastroscoj>e.  Un- 
fortunately, the  simple  mention  of  this  author's  name  almost  ex- 
hausts the  literature  of  the  subject,  for  the  instrument,  as  con- 
structed by  Leiter  (of  Yienna),  is  so  expensive  and  at  the  same  time 
so  difiicult  to  manipulate,  unless  both  patient  and  physician  have 
been  well  trained,  that  its  use  has  been  very  limited.  The  results 
which  Mikulicz :};  obtained  in  carcinoma  of  the  pylorus  are  of  diag- 
nostic interest.  In  the  normal  stomach  the  pylorus  appears  as  a  long 
slit  or  a  triangular,  oval,  and  often  a  circular  opening,  surrounded 
by  a  ring  of  bright-red  folds  and  projections  of  mucous  membrane, 
which  are  in  active  motion  and  show  an  infinite  number  of  changes 


These  sounds  were  first  mentioned  in  1864  by  Natanson,  and  were  carefully 
studied  by  Zencker  and  also  by  Meltzer.  The  literature  of  the  subject  may  be  found 
in  Ewald,  loc.  cit.,  p.  92. — Tr.] 

*  Meltzer.  Schluckgerausche  im  Scorbiculus  cordis  und  ihre  physiologische 
Bedeutung.     Centralbl.  f.  d.  med.  Wissenseh.,  1883,  No.  1. 

f  H.  Dirksen.  Beitrag  zur  Lehre  von  den  Schluckgerauschen.  Inaug.  Dissert., 
Berlin,  1885. 

X  Wiener  med.  Wochenschrift,  33te  Jahrgang,  S.  748. 


TECHNIQUE   OP  LAVAGE.  63 

of  form.  But  in  neoplasms  at  the  pylorus  tins  region  is  smooth, 
pale,  without  the  above-described  folds  and  projections,  and  abso- 
lutely motionless.  This  would  thus  be  a  valuable  aid  in  diagnosis, 
had  not  Pribram*  reported  a  case  of  pyloric  carcinoma  —  at  all 
events,  without  gastroscopic  examination,  in  which  there  were 
active  movements  of  the  tumor,  i.  e.,  a  change  in  its  size  synchro- 
nous with  active  contractions  of  the  whole  stomach. 

The  use  of  the  gastrodiaphane  has  been  suggested  by  Einhorn.f 
This  instrument  consists  of  a  small  electric  light,  which  is  introduced 
into  the  stomach ;  the  contours  of  this  organ  are  outlined  by  the 
light  shining  through  the  gastric  wall  and  the  abdominal  parietes. 
Whether  this  procedure  will  be  of  any  practical  value  must  be 
determined  by  experience.  Similar  experiments  were  made  on 
animals  as  long  ago  as  1867  by  Milliot. 

The   Technique  of  the   Treatment  of  Stomach   Diseases. — Of  the 

numerous  methods  from  time  to  time  proposed  for  washing  otit  the 
stomach  or  irrigating  its  mucous  metnhrane,  the  best  is  the  simple 
siphon  method,  concerning  which  we  may  speak  as  of  the  ex- 
pression method,  simplex  veri  sigilluin.  A  glass  funnel  is  attached 
to  the  free  end  of  the  stomach-tube  by  means  of  a  piece  of  rubber 
tubing  about  one  metre  [one  yard]  \  long,  and  by  alternately  raising 
and  lowering  the  funnel  the  stomach  may  be  filled  or  emptied.  The 
simple  siphon  action  is  all  that  is  needed,  since,  with  very  few 
exceptions,  we  can  undertake  the  operation  at  a  time,  or  after  such 
meals,  when  tliere  is  no  danger  of  having  the  openings  of  the  tube 
plugged ;  and  even  if  small  pieces  of  meat  and  similar  substances 
are  aspirated  into  the  eyelets,  they  can  easily  be  dislodged  by 
holding  the  funnel  high  up.  I  consider  it  entirely  irrelevant 
whether  we  use  a  continuous  stream  with  a  double-current  tube  or 

*  Pribram.  Zur  Semiotik  des  Pyloruscarcinoms.  Prager  med.  Woehenschr., 
1884,  S.  53. 

f  M.  Einhorn.  Die  Gastrodiaphanie.  New-Yorker  med.  Monatschrift,  Novem- 
ber, 1889.     [The  instrument  is  condemned  by  Boas,  loc.  cit.,  S.  100. — Tr.] 

X  [A  small  piece  of  glass  tubing,  the  caliber  of  which  is  somewhat  smaller  than 
that  of  the  stomach-tube,  is  very  convenient  for  connecting  the  latter  with  the 
tubing  attached  to  the  funnel ;  through  it  we  may  also  see  the  nature  of  the 
fluid  raised  from  the  stomach,  and  can  also  readily  determine  when  it  comes  up 
perfectly  clear. — Tr.] 


64: 


DISEASES  OP  THE  STOMACH. 


whether  we  fill  and.  empty  the  stomach  alternately ;  if  anything,  I 
prefer  the  latter,  since  the  rapid  raising  and  depressing  of  the  fun- 
nel agitates  the  fluid  in  the  stomach  more  forcibly,  and  mucus  and 
other  solid  substances  caught  in  the  folds  of  the  mucosa  may  be 
more  easily  removed  mechanically.  I  prefer  to  use  a  large  glass 
funnel  of  about  two  litres  [two  quarts]  capacity,  with  a  diameter 
of  20  centimetres  [8  inches]  ;  this  is  attached  to  a  rubber  tube  of 
suitable  length,  which  is  joined  to  the  upj)er  end  of  the  stomach- 
tube  [by  a  small  piece 
of  glass  tubing].  The 
funnel  rests  in  a  wood- 
en frame  (Fig.  4)  on 
the  floor  [or  table], 
and  is  here  filled  with 
the  requisite  amount 
of  water  or  other  fluid 
used,  and  is  then  raised 
to  a  height  suitable  to 
obtain  the  amount  of 
pressure  desired. 

The  water  escapes 
from  the  various  open- 
ings in  the  tube,  as 
from  a  sprinkler,  so 
that,  by  gradually 
withdrawing  the  tube 
a  little,  the  various  portions  of  the  stomach  may  be  successively 
irrigated.  To  siphon  the  water  out  of  the  stomach,  the  funnel  is 
again  placed  in  the  wooden  frame,  and  thus  any  foreign  substances 
that  may  be  present  may  rise  in  it,  and  can  be  obtained  for  exam- 
ination if  desired.  If  one  is  alone,  this  technique  is  much  more 
convenient  than  to  work  with  a  small  funnel.  For  consultation 
practice  out  of  the  office,  I  use  a  small  hard-rubber  funnel  of 
about  300  c.  c,  [f  |  x]  capacity. 

Siphonage  of  the  stomach  by  elevating  and  depressing  a  funnel 
can  not  be  done  by  the  patient  alone.  Yet,  in  many  cases,  it  is 
essential  that  the  patient  should  wash  out  his  own  stotaach ;  the 


Fig.  4.— Stand  toi  holdiug  funnel  of  stomach-tube. 


AUTO-LA VAGE   OF  STOMACH. 


65 


first  requisite  is,  of  course,  to  learn  to  introduce  the  tube  himself,  a 
manipulation  which  most  patients  acquire  very  readily.  Here,  too, 
the  simplest  method  will  suffice.  For  siphonage,  the  following 
will  be  found  to  be  convenient :  One  extremity  of  the  horizontal 
portion  of  a  glass  T-tube  [c,  Fig.  5]  is  connected  with  the  stomach- 
tube  [(*],  the  other  extremity 
is  joined  to  an  irrigator  by 
means  of  a  soft-rubber  tube 
[d],  a  hard-rubber  stop-cock  * 
intervening ;  to  the  free  end 
of  the  vertical  portion  is  at- 
tached a  rubber  tube  [^]  about 
one  metre  [one  yard]  long. 
The  patient  sits  near  the  irri- 
gator, which  has  previously 
been  filled  and  placed  at  a 
suitable  height ;  the  tube  is 
introduced  into  the  stomach 
while  the  stop-cock  is  kept 
closed,  and  the  open  end  of 
the  rubber  tube  [^]  from  the 
vertical  piece  of  the  T-tube 
is  compressed  with  the  fin- 
gers of  one  hand.  With  the  other  hand  he  then  opens  the  stop- 
cock after  the  tube  is  in  the  stomach,  and  then  allows  a  sufficient 
quantity  of  fluid  to  pass  into  the  stomach.  As  soon  as  he  feels 
the  distention  the  stop-cock  is  closed,  and  the  fingers  are  taken 
off  the  vertical  tube  ;  this  allows  the  fluid  to  be  siphoned  from 
the  stomach.  By  repeating  this  the  stomach  may  be  filled  and 
emptied  as  often  as  desired.  Many  patients  become  very  skillful, 
and  often  do  not  know  when  to  stop,  so  that  finally  they  may  even 
abuse  it.  Numbers  of  such  cases  can  be  found  reported,  es^^ecially 
in  French  literature. 

Electricity  may  be  applied  to  the  stomach,  either   by  placing 


Fig.  5. — From  Peppei-'s  System  of  Medicine 
(after  Leube) — Tk. 


*  [This  is  not  essential ;  it  may  be  replaced  by  a  pinch-cock  placed  on  the  tub- 
ing (d) ;  it  will  also  be  found  convenient  to  have  one  upon  e. — Tr.] 


66  DISEASES  OF  THE  STOMACH. 

botli  electrodes  on  the  anterior  abdominal  wall  or  by  introducing 
one  of  them  into  the  stomach  and  closing  the  current  by  means  of 
another  electrode  upon  the  abdominal  wall,  the  latter  electrode, 
according  to  well-known  physical  laws,*  having  as  large  a  cross- 
section  as  possible.  The  electrode  which  passes  into  the  stomach 
usually  consists  of  a  copper  wire  whose  lower  end  bears  a  leather- 
covered  knob,  while  the  wire  itself  has  been  passed  through  a  stom- 
ach-tube. To  screw  on  the  knob,  the  wire  must  possess  a  certain 
thickness,  but  this  renders  it  stiff  and  unpliable.  This  may  be  obvi- 
ated by  a  preliminary  hammering  of  the  wire  in  the  fire,  which  ren- 
ders it  so  soft  and  supple  that  it  will  assume  any  curve  desired.  I 
usually  cover  it  with  a  piece  of  ordinary  rubber  tubing  of  small  cali- 
ber. The  patient  drinks  one  or  two  glassf uls  of  water  before  intro- 
ducing the  electrode,  or,  in  cases  of  marked  dilatation,  the  stomach 
may  be  filled  through  a  tube.  Einhorn  f  has  recently  devised  a  very 
useful  electrode.  It  consists  of  an  ovoid  perforated  hard-rubber 
capsule  about  the  size  of  an  almond ;  within  is  a  button  electrode 
which  is  connected  with  a  very  delicate  wire  covered  with  a  very 
fine  rubber  tube.     The  accompanying  drawing  (Fig.  6)  represents 


Fig.  6. — Deo-lutable  stomach-electrodo. 


the  instrument  in  its  natural  size.  The  method  is  as  follows  :  "  The 
patient  drinks,  best  while  fasting,  one  or  two  glasses  of  water  ;  after 
opening  the  mouth  widely  the  capsule  is  placed  far  back  on  the 


*  Vide  C.  Rieger.     Grundriss  der  medicinischen  Eleetricitatslehre.    Jena,  1887. 

f  Einhorn.  New  Method  for  Direct  Electrization  of  the  Stomach,  New  York 
Medical  Record,  May  9,  1891,  p.  530.  [Also  Therapeutic  Results  of  Direct  Elec- 
trization of  the  Stomach.  New  York  Medical  Record,  January  30  and  February  6, 
1892. — Stockton.  A  New  Gastric  Electrode,  ibid.,  November  9,  1889  ;  Clinical 
Results  of  Gastric  Faradization,  Amer.  Jour.  Med.  Sciences,  July,  1890.  Both 
faradaic  and  galvanic  currents  may  be  employed ;  the  latter  being  especially  indi- 
cated for  the  relief  of  gastralgia  and  nervous  vomiting,  the  positive  pole  being  in 
the  stomach. — Tr.] 


ELECTRIZATION  OF  STOMACH.  07 

root  of  tlie  tongue,  and  the  j)atient  is  told  to  swallow.  He  again 
drinks  some  water,  and  the  electrode  finds  its  way  into  the  stomach 
without  further  assistance."  The  circuit  is  closed  by  means  of  a 
flat  electrode  placed  upon  the  abdomen.  But,  since  many  persons 
can  not  swallow  the  capsule,  or,  if  swallowed,  it  frequently  stays  in 
the  oesophagus,  I  have  drawn  the  wire  through  a  somewhat  larger 
rubber  tube,  something  like  a  Nelaton  catheter,  number  13.  This 
small  instrument  can  be  readily  introduced  in  the  same  way  as  a 
stomach-tube,  and  yet  is  delicate  enough  to  be  readily  tolerated  for 
some  time  in  the  mouth  or  stomach.  I  am  very  well  satisfied  with 
this  method  of  using  the  electrode,  and  have  obtained  very  satisfac- 
tory results  which  I  shall  discuss  later  on.  Yon  Ziemssen*  con- 
siders this  intraventricular  method  of  electrization  inadequate  be- 
cause the  electrode  always  reaches  only  the  left  part  of  the  greater 
curvature,  since  the  direction  of  the  axis  of  the  oesophagus  to  the 
left  deviates  it  into  this  direction — i.  e.,  to  the  left  iliac  region — and 
hence  a  uniform  action  upon  the  entire  organ  is  impossible ;  and, 
further,  even  disregarding  this,  the  procedure  is  very  tiring  and 
exhausting  for  feeble  patients.  But  it  is  known  that,  by  filling  the 
stomach  wath  water,  the  current  is  distributed  in  all  directions,  and 
acts  upon  the  walls  of  the  viscus  so  far  as  they  are  under  water  ; 
and  as  to  the  jDOSsible  feebleness  of  the  jDatients,  the  method  may 
nevertheless  be  used,  and  is  used  on  robust  persons  as  a  rule.  Yon 
Ziemssen's  experience  in  this  field  must  date  from  a  time  when  the 
entire  local  treatment  of  the  stomach  had  not  reached  its  present 
perfection,  and  consequently  all  these  procedures  must  have  been 
more  tedious  and  exhausting  than  they  are  to-day. 

The  entire  digestive  tract  may  be  electrized  by  having  one  elec- 
trode in  the  stomach  and  the  other  in  the  rectum,  the  electrode 
being  introduced  after  having  cleansed  the  intestines  with  an  ene- 
ma. Schillbach  f  tried  this  method  on  rabbits  without  observing 
any  effect,  but,  as  it  appears,  neglected  the  preliminary  cleansing 
of  the  intestines.    In  several  cases  of  atony  of  the  bowels,  combined 

*  Von  Ziemssen.     Ueber  die  physikalische  Behandlung  chronischer  Magen-  und 
Darmkrankheiten.     Klinische  Vortrage.  xii.  Leipzig,  1888. 

t  E.  Schillbach.     Stndien  liber  den  Einfluss  der  Electricitat  aiif  den  Darm. 
Virchow's  Archiv,  Bd.  109,  S.  284. 
6 


68  DISEASES  OF  THE  STOMACH. 

■with  a  moderate  dilatation  of  the  stomach,  I  have  obtained  surpris- 
ing results,  but  in  others  none  whatsoever. 

A  series  of  investigations  has  already  been  made  to  show  the 
possibility  of  influencing  the  stomach  with  the  electric  current ;  for 
example,  von  Ziemssen  and  Caragiosiadis,*  Bocci,f  and  others.  Ac- 
cording to  these  observations,  the  external  application  of  the  elec- 
trodes causes  only  moderate  contractions,  which  are  of  very  doubtful 
therapeutic  value  ;  the  constant  current  produces  nothing  more  than 
a  localized  contraction.  The  induced  current,  especially  when  it  is 
applied  directly  to  the  mucous  membrane,  is  more  powerful,  and 
may  cause  the  secretion  of  gastric  juice  or  mucus,  as  Bocci  has 
shown  on  a  dog  with  a  gastric  fistula.  Yon  Ziemssen :}:  says  that  in 
dogs  the  direct  passage  of  a  powerful  current  of  both  kinds  increases 
the  secretion  of  gastric  juice.  Regnard  and  Loye*  observed  the 
same  thing  in  an  executed  criminal  whose  vagi  were  stimulated  by 
an  electric  current  forty-five  minutes  after  his  death.  The  experi- 
ments conducted  by  Sievers  and  myself  ||  showed  positively  that  fara- 
dization of  the  abdominal  wall  with  a  strong  current  and  broad,  flat 
electrodes  has  a  decided  effect  on  the  stomach.  In  many  persons  on 
whom  the  salol  test  (see  page  54)  was  tried  for  this  j)urpose,  it  was 
found  that  the  reaction  in  the  urine  occurred  earlier  than  usual,  and 
hence  the  salol  must  have  been  carried  on  into  the  intestines  more 
rapidly  as  the  result  of  more  powerful  contractions  [of  the 
stomach]. 

There  is  a  good  deal  of  clinical  evidence  of  the  beneficial  effects 
of  the  constant,  but  more  especially  of  the  induced,  current.  Many 
reliable  writers  agree  on  this  point,  as  Kussmaul,  Leube,  Fiirstner, 
Burkart,  and  others.  Even  Ziemssen  claims  good  results  from  the 
percutaneous  electrization  of  the  stomach  with  large  electrodes  of 
about  500  to  600  square  centimetres  [about  80  to  100  square  inches] 
area,  and  strong  currents  combined  with  a  brief  faradic  brushing  of 
the  skin  of  the  abdomen,  chest,  and  back  for  two  to  three  minutes. 

*  Caragiosiadis.  Die  locale  Behandlung  der  Gastro-ectasie  mit  dem  elektrischen 
Strom.     Inaug.  Dissert..,  Munich,  1878. 

f  Bocci.  Elettricita  nello  storaaco  dell'  animale  e  dell'  uomo.  Lo  sperimentale, 
1881,  p.  561. 

X  Von  Ziemssen,  loc.  cit.,  p.  7. 

*  Quoted  by  von  Ziemssen,  ibid.,  p.  7.  1  Loc.  cit. 


ELECTRIZATION  OF  STOMACH.  69 

As  the  result  of  tliis  there  is  a  feeling  of  warmth  and  invigoration, 
marked  improvement  of  the  appetite,  and  decidedly  increased  di- 
gestive activity.  I  can  corroborate  all  this  ;  for  example,  patients 
with  nervous  anorexia  frequently  eat  their  food  with  relish  and 
digest  it  fairly  well  immediately  after  the  application  of  electricity. 
It  must,  unfortunately,  be  admitted  that  all  such  therapeutic  proced- 
ures which  may  be  complicated  by  other  factors  do  not  of  them- 
selves prove  much  until  we  have  the  ocular  proof  of  actually  seeing 
the  stomach  contract  under  the  influence  of  the  electric  current, 
especially  as  Pepper,*  in  a  case  of  pyloric  cancer  with  dilatation 
and  visible  peristalsis,  could  not  increase  the  latter  either  with  a  fara- 
dic  or  a  constant  current,  but  could  only  cause  a  contraction  of  the 
abdominal  muscles.  Surely,  by  using  Einhorn's  stomach-electrode, 
or  my  modification  of  it,  contractions  of  the  muscular  fibers  of  the 
stomach  themselves  must  be  obtained,  and,  as  I  have  already  stated, 
and  as  I  shall  discuss  later  on,  excellent  results  have  been  obtained, 
especially  in  gastric  dilatation.  Baradui  f  has  also  obtained  very 
satisfactory  effects  in  stomach  disorders  from  electrisation  intra- 
stomacale  and  galvanisation  d%i  grand  syvi^aihique  an  cou. 

At  this  place  I  might  also  speak  of  the  gymnastics  of  the  abdom- 
inal organs,  especially  of  ')nassage  and  the  hydr other apeutic  proced- 
ures of  the  stomach  /  but,  disregarding  the  simplest  measures,  like  rub- 
bing with  cold  or  gradually  cooled  water,  compresses,  and  half  baths 
and  wet  packs,  with  or  without  douches,  the  household  remedies  of 
hydrotherapy,  as  it  were,  the  methodical  treatment,  especially  when 
combined  with  electric  baths,  requires  the  direction  of  a  specialist 
and  apparatus  which  is  only  to  be  found  and  properly  used  in  hydro- 
therapeutic  establishments.  I  would  also  recommend  the  same  in 
regard  to  massage,  and,  whenever  it  is  possible,  it  ought  only  to  be 
done  by  properly  trained  persons. 

Finally,  these  chapters  on  technique  would  be  incomplete  if  I 
failed  to  state  that  the  credit  of  having  been  the  first  to  use  the 
aniline  colors  for  detecting  free  acids,  especially  hydrochloric  acid, 
and  to  call  attention  to  the  clinical  value  of  these  reactions,  belongs 

*  Pepper.     A  Case  of  Scirrhus  of  the  Pylorus,  with  Remarks  on  the  Electrical 
Excitation  of  the  Stomach.     Philadelphia  Medical  Times,  May,  1871. 
f  Baradui.    Journal  de  la  Soc.  scient.,  1891,  No.  10,  p.  97. 


YO  DISEASES  OF  THE  STOMACH. 

to  two  Frenclimen — MM.  Laborde  and  Dusart — who  as  long  ago 
as  1874  published  a  paper  on  the  Nouvelles  recherches  sur  Vacide 
libre  du  sue  gastrique.  They  first  used  aniline  sulphate  and  lead 
peroxide,  and  later  (1877)  methyl-violet.  This,  having  been  ac- 
knowledged by  von  den  Yelden  *  in  1879  and  having  never  been 
contradicted,  at  once  establishes  the  claims  for  priority  recently  put 
forth  by  Laborde.f 

*  Deutsch.  Arch,  flir  klin.  Med.,  Bd.  23,  S.  374. 

f  Laborde.    Les  colorants  appliques,  etc.     Bulletin  general  du  Therap.,  1887, 
30  janv. 


LECTUEE  III. 

STENOSES    AND    STEICTUEES    OF    THE    CAEDIA. 

Gentlemen  :  Disregarding  the  obstructions  situated  liiglier  up 
in  the  mouth,  throat,  and  oesophagus,  and  the  accidental  swallowing 
of  foreign  bodies  (bones,  etc.)  which  become  impacted  at  the  cardia, 
and  relegating  them  to  the  hands  of  the  surgeon,  we  find  that  the 
entrance  to  the  stomach — the  mouth  or  cardia — may  be  obstructed 
in  two  ways,  and  the  swallowed  food  thus  more  or  less  impeded  in 
entering  the  stomach.  These  are  (1)  spastic  contraction  and  (2) 
cicatricial  tissue,  more  especially  new  growths  at  the  site  referred 
to.  The  latter  are  never  exclusively  limited  to  the  ring  of  the 
cardia,  but  extend  above  into  the  oesophagus  or  below  into  the 
stomach. 

The  symptoms  to  which  these  conditions  give  rise  possess  a 
great  deal  in  common  in  spite  of  the  most  manifold  causes  which 
may  produce  them.  The  fundamental  feature  is  the  inability  to 
convey  the  food  which  has  been  swallowed  into  the  stomach,  and 
from  this  obstruction  to  the  introduction  of  food  the  other  compli- 
cating phenomena  are  developed. 

In  most  cases  the  passage  through  the  cardia  is  gradually  oc- 
cluded. In  the  beginning  there  are  times  when  absolutely  no  ob- 
struction to  swallowing  seems  to  exist ;  while  at  others  the  patients 
distinctly  feel  that  the  food  is  retarded  above  the  stomach,  "  that  it 
lies  like  lead  above  the  stomach,"  but  that  by  repeated  movements 
of  swallowing,  by  waiting,  and  drinking,  it  may  be  forced  past  the 
narrowed  spot  into  the  viscus.  At  this  time  fluids  and  very  soft 
foods  do  not  usually  cause  any  difficulty,  but  the  obstruction  is  more 
marked  the  more  consistent  the  food  and  the  larger  the  morsels 
that  are  eaten ;  for  instance,  if  too  large  a  piece  of  meat  or  the 
like  be  accidentally  or  hurriedly  swallowed,  it  can  readily  cause  a 


72  DISEASES  OF  THE  STOMACH. 

transient  complete  closure  which  will  not  even  permit  fluids  to  pass. 
Later  on  the  intervals  grow  progressively  shorter  and  finally  disap- 
pear entirely,  while  the  necessity  of  taking  food  in  a  fluid  form  be- 
comes continually  greater,  the  choice  of  food  continually  more  lim- 
ited. Then  a  new  symptom  appears  in  the  form  of  regurgitation  of 
the  food,  which  is  brought  up  unchanged  except  for  the  admixture 
of  mucus  or  saliva ;  for  in  the  same  degree  that  the  obstruction  at 
the  cardia  becomes  greater  and  more  marked,  the  masses  which  are 
swallowed  must  gather  more  and  more  above  the  opening,  so  that 
they  can  readily  return,  should  the  lower  sections  of  the  oesophagus 
be  the  seat  of  peristaltic  contractions,  or  should  they  be  compressed 
from  without  by  coughing,  etc.  A  further  result  is  seen  in  the  con- 
secutive dilatation  of  the  oesophagus,  which  may  appear  the  more 
readily  since  a  slight  congenital  expansion  is  occasionally  found  in 
it  close  to  the  entrance  into  the  stomach,  forming  what  Luschka 
calls  the  "  ante-stomach  "  (  Vormagen). 

Yet  von  Ziemssen  and  Zenker  *  rightly  remark  that  this  dilata- 
tion is  by  far  not  so  frequently  found  as  one  would  infer  from  the 
statements  in  the  text-books.  Of  course,  a  great  deal  depends  on 
what  is  understood  by  "  dilatation  "  ;  and  if  these  authors  speak  of  a 
case  of  ectasis  of  the  oesophagus  with  a  diameter  of  5  centimetres 
[2  inches]  in  the  widest  part  of  the  dilated  portion,  I  can  oppose 
thereto  what  I  found  in  two  out  of  three  autopsies  in  cases  of  strict- 
ure of  the  cardia,  in  which  the  widest  part  of  the  oesophagus,  situ- 
ated 5  centimetres  [2  inches]  above  the  cardia,  measured  6*2  or  pos- 
sibly 6  centimetres  [2|-  to  2f  inches],  while  higher  up  the  diameter 
was  only  3  centimetres  \1\  inches].  Neithsr  of  the  cases  impressed 
one  in  any  way  as  important  ectases  of  the  oesophagus  from  the 
mere  inspection  of  the  anatomical  preparations. 

Thus,  as  far  as  the  space  will  permit,  the  ingesta  collect  in  the 
oesophagus  above  the  cardia  till  they  irritate  its  walls  to  such  an  ex- 
tent that  they  are  reflexly  expelled  by  the  pressure  due  to  the  strong 
efforts  at  coughing.  These  efforts  at  expulsion  and  vomiting,  fol- 
lowing at  first  only  after  eating,  may  finally  also  appear  between 


*  Von  Ziemssen  und  Zenker.     Oesophaguskrankheiten,  in  Handbuch  der  Krank- 
heiten  des  chylopoetischen  Apparates,  i,  p.  33. 


SYMPTOMS   OP  STENOSIS   OF   CARDIA.  73 

meals  without  food  having  been  taken  immediately  before.  At  first 
the  regurgitation  of  food  is  mostly  incomplete,  since  the  oesophageal 
contents  are  forced  up  but  a  short  distance  and  then  sink  down 
again  after  that  jDortion  which  has  in  the  mean  time  become  fluidi- 
fied passes  by  the  stricture.  Later  on  this  takes  place  in  a  more 
marked  degree,  and,  as  Brinton  ^  says,  it  may  be  easily  understood 
that  since  the  oesophageal  contents  are  compressed  by  the  normal 
peristalsis  which  runs  from  above  downward,  a  central  core  must 
escape  above,  just  as  this  occurs  under  similar  circumstances  in  the 
centrally  perforated  piston  of  a  pump  or  syringe. 

The  expelled  masses  consist  of  the  unchanged  ingesta  mixed 
with  mucus  and  saliva,  in  w^hich  chemical  examination  completely 
fails  to  show  the  ]3roducts  of  gastric  digestion.  At  times  the  spe- 
cific constituents  of  a  neoplasm  may  be  recognized  under  the  micro- 
scope. Unless  specially  colored  fluids  (red  wine,  fruit  -  juices, 
strongly  colored  medicines,  etc.)  have  been  taken,  the  vomited  mat- 
ter usually  has  a  grayish-white  or  yellowish-gray  color,  without  a 
trace  of  bile.  I  wish  to  call  particular  attention  to  this  last  point, 
for  the  absence  of  biliary  coloring  matters  may  be  of  the  utmost  im- 
portance in  deciding  whether  we  have  to  deal  with  oesophageal  or 
gastric  contents,  a  decision  which  at  times  may  be  very  difficult. 
Exceptionally  food  which  has  been  eaten  at  a  previous  meal  is 
brought  up,  while  none  of  that  taken  last,  so  far  as  it  possesses 
characteristic  constituents,  is  to  be  found.  Since  this  is  not  a  rare 
occurrence  in  diverticula  of  the  oesophagus,  and  one  which  under 
the  then  existing  circumstances  can  be  readily  explained,  it  might  in 
such  a  case  cause  the  diagnosis  of  diverticulum  to  be  established  or 
its  presence  to  be  suspected.  In  this  connection  1  can  refer  to  the 
autopsies  made  by  me  in  two  cases  of  stenosis  of  the  cardia  with 
dilatation,  but  without  the  formation  of  any  diverticula,  in  which 
the  condition  described  had  been  repeatedly  observed,  and  conse- 
cjuently  the  question  of  the  presence  of  a  diverticulum  was  fi*equent- 
ly  debated  during  life,  but  in  which,  as  I  have  said,  the  oesophagus 
was  entirely  free  from  any  such  formation.  Thus  this  condition  can 
not  be  regarded  as  a  positive  diagnostic  factor  indicating  an  existing 

*  W.  Brinton.     Lectures  on  the  Diseases  of  the  Stomach.     London,  1864,  p.  10. 


Y4  DISEASES  OF  THE  STOMACH. 

diverticulum.  It  could  only  come  into  play  in  case  of  partial  pervi- 
ousness  of  the  stricture,  in  which  certain  articles  of  food  could  pass 
through  more  rapidly,  while  others  would  be  detained  there  for  a 
longer  time. 

Another  result  of  the  obstruction  to  the  passage  of  nourishment, 
and  growing  j_>«W  2^^^^'^''  with  the  increasing  constriction  of  the 
cardiac  orifice,  is  the  disturbance  and  impairment  of  the  nutrition  of 
the  patient,  which  finally  leads  to  a  marked  degree  of  emaciation 
and  weakness.  We  see  groove-like  hollowing  of  the  abdomen,  the 
epigastric  and  hypochondriac  regions  being  specially  retracted,  and 
the  pulsation  of  the  aorta  can  be  very  plainly  felt  through  the  walls ; 
the  muscles  and  fat  w^aste  away  more  or  less  ;  the  skin  becomes  pale, 
waxy,  or,  especially  in  the  face,  assumes  the  specific  yellowish-green 
color  of  the  cancerous  cachexia.  The  eyes  are  sunken,  the  lips  thin, 
the  nose  and  cheek-bones  become  pointed  and  prominent.  .  The 
tongue  usually  has  a  thick  white  coat,  and,  despite  careful  cleansing 
of  the  mouth,  a  fetid  odor  emanates  from  it.  The  stools  are  small 
and  tardy,  and  the  faeces  are  hard,  dry,  and  scybalous  ;  the  urine  is 
scanty,  with  few  solid  constituents — in  one  case  I  was  scarcely  able 
to  find  a  trace  of  the  chlorides — and  toward  the  end  of  life  now  and 
then  contains  albumen.  Pufiiness  over  the  malleoli,  and  also  slight 
oedema  of  the  legs,  usually  appear  toward  the  end  of  the  disease. 

To  be  sure,  the  picture  just  drawn  is  very  essentially  influenced 
by  the  causative  factor  of  the  disease  and  by  the  constitution  of  the 
patient,  especially  in  cases  of  spastic  contraction,  in  which,  although 
the  resulting  symptoms  may  be  really  severe  and  very  marked,  they 
do  not  as  a  rule  lead  to  the  most  extreme  consequences ;  but  even  in 
organic  stenosis  of  the  cardia  you  will  find  that  the  patency  of  this 
orifice  and  the  general  bodily  condition  do  not  always  correspond. 
I  have  repeatedly  seen  cases  in  which  the  stricture  was  very  well 
marked,  but  in  which  the  appearance  and  general  strength  were  rela- 
tively favorable,  even  though  the  patients  complained  of  having 
fallen  off  from  their  former  condition.  On  the  other  hand,  the  can- 
cerous cachexia  caused  by  carcinoma  of  the  cardia,  which  is  to  be 
regarded  as  the  result  of  constitutional  intoxication,  may  reach  a 
high  degree  without  the  presence  of  a  correspondingly  great  nar- 
rowing of  the  cardia.     It  is  a  peculiarity  of  cancer  of  the  cardia 


SYMPTOMS  OF  STENOSIS  OF  CARDIA.  Y5 

that  the  reaction  upon  the  general  system,  so  far  as  it  is  expressed 
by  metastases,  adenopathies,  etc.,  is  comparatively  slight. 

Among  the  least  frequent  of  the  common  symptoms  appearing 
in  the  course  of  the  disease  are  local  or  more  diffuse  pains.  True 
cardialgia — i.  e.,  marked  cramp-like  pain,  with  a  definite  localization 
in  the  epigastric  region — does  not  occur ;  and  thus,  too,  the  severe 
radiating  pains  which  so  often  accompany  carcinomatous  or  ulcera- 
tive processes  of  the  stomach  are  almost  always  absent.  Should 
they  be  present,  they  occasion  the  suspicion  that  the  process  is  not 
limited  to  the  cardia.  Most  frequently  the  patients  complain  of  a 
slight  burning  or  boring  pain,  or  only  of  a  feeling  of  pressure  in  the 
region  of  the  ensiform  cartilage.  At  times,  and  rather  in  the  minor- 
ity of  cases,  this  may  be  increased  by  pressure  from  without  on  the 
ensiform  cartilage.  As  a  rule,  swallowing  causes  either  no  special 
increase  of  the  pain  or  none  at  all.  In  one  of  my  cases  in  which  tlie 
carcinomatous  neoplasm  had  invaded  the  retro-peritoneal  tissues  the 
patient  complained  of  pain  in  the  lumbar  region.  In  many  cases 
pain  is  entirely  absent. 

I  shall  now  present  a  case  of  stenosis  of  the  cardia,  and  annex 
the  discussion  of  diagnosis  and  therapy  thereto : 

Mr.  P.,  restaurateur,  forty-eight  years  old,  is  a  man  of  large  and 
marked  bony  build.  At  a  glance  it  is  evident  that  he  must  lately,  and  in 
a  comparatively  short  time,  have  lost  considerable  flesh.  Not  that  his  face 
has  emaciated  so  much,  but  that  his  clothes  undoubtedly  were  cut  for  a 
much  stouter  man.  Indeed,  he  tells  us  that  he  has  fallen  off  markedly 
only  for  the  past  ten  weeks,  because  he  has  suffered  from  "  stomach 
trouble,"  with  constantly  increasing  severity.  Without  any  warning  a 
sensation  was  developed  as  if  the  food  after  eating  were  held  fast  in  the 
region  of  the  stomach  "  as  if  by  a  cork  " ;  this  feeling  disappeared  only  after 
he  had  emptied  his  stomach  by  vomiting.  As  I  have  said,  in  the  begin- 
ning this  took  place  only  after  a  meal,  but  lately  he  has  had  to  vomit 
even  when  he  had  not  eaten  anything.  The  stomach  is  more  apt  to  retain 
fluids  and  very  soft  articles  of  food,  but  he  is  forced  to  vomit  a  portion 
even  of  these.  The  vomited  masses  have  always  been  only  slightly 
changed,  and  mixed  with  large  quantities  of  tough  mucus.  No  pain  or 
belching.  Appetite  good.  Bowels  somewhat  constipated,  but  easily  regu- 
lated by  cathartics.  Lately  a  marked  feeling  of  weakness  has  developed, 
and  the  patient  spends  the  greater  part  of  the  day  lying  down. 

No  family  history  of  cancer.  Father  died  of  paralysis  ;  mother  is  still 
living.  Physical  examination  of  the  gastric  region  in  the  patient  is 
entirely  negative;  the  abdominal  walls  are  slightly  retracted;  percussion 
shows  that  neither  the  stomach  nor  the  neighboring  organs,  liver,  spleen, 


76  DISEASES  OP  THE  STOMACH. 

and  intestines,  are  of  abnormal  size.  Palpation  is  also  negative  regarding 
a  tumor  or  any  other  abnormity  in  tbe  abdominal  cavity.  The  greater 
curvature  apparently  crosses  the  mid-line  2  centimetres  [f  inch]  above  the 
umbilicus.  At  the  same  time  distention  of  the  colon  from  the  rectum,  by 
means  of  the  double  bulb  of  a  spray  apparatus,  shows  that  the  transverse 
colon  immediately  appears  as  a  swelling  under  the  free  border  of  the  ribs; 
therefore,  at  any  rate,  no  enlargement  of  the  stomach  can  exist.  The 
oesophageal  sound  passes  with  ease  through  the  entrance  of  the  oesopha- 
gus, and  through  its  entire  length;  but  after  it  is  introduced  44  centi- 
metres [17f  inches]  it  impinges  upon  a  firm  obstruction,  just  as  if  its 
point  had  struck  against  the  bottom  of  a  sack.  This  makes  the  patient 
force  up  a  large  quantity  of  a  white,  mucous  fluid,  mingled  with  single 
lumps  of  tough,  glassy  mucus.  It  produces  no  pain,  occasioning  rather 
severe  choking  by  reflex  irritation.  All  efforts  to  pass  the  sound  further 
are  fruitless,  in  spite  of  our  using  sounds  of  different  calibers  down  to  that 
of  a  goose-quill.  No  change  is  produced  by  varying  the  posture  of  the 
patient  to  the  right  or  left  side  or  to  the  knee-elbow  position.  While  in 
the  latter  position  I  again  palpated  the  abdomen,  but  was  still  unable  to 
detect  any  abnormities. 

Examination  of  the  fluid  brought  up,  amounting  to  about  100  c.  c. 
[f  I  iij],  gives  the  following  result  :  Eeaction  with  blue  and  red  litmus- 
paper  is  neutral  ;  it  gives  a  light  burgundy-red  color  with  iodine,  contains 
sugar,  and  has  a  slight  diastatic  action  ;  salts  of  lactic  acid  present  in 
minute  quantities  ;  peptone  and  pepsin  entirely  absent.  Even  after  acidu- 
lating the  fluid,  mixing  it  with  albumen  and  heating,  it  possesses  no 
digestive  action.  I  here  show  you  the  test  in  question,  in  which  the  un- 
changed disk  of  albumen  lies  at  the  bottom  of  the  test-tube,  and  with 
which  the  biuret  reaction  gives  a  negative  result. 

Under  the  microscope,  in  addition  to  numerous  starch  graniiles  which 
have  been  colored  blue  by  the  iodine,  we  find  a  few  muscular  fibers  en- 
tirely intact,  and  numbers  of  fat-cells  of  various  sizes.  Eod-shaped  ba- 
cilli are  present  in  small  numbers.  On  the  other  hand,  we  do  not  find  any 
yeast-cells  or  sarcinae,  or  any  cellular  elements  which  might  originate  from 
a  possible  tumor.  The  patient  tells  us  that  about  three  hours  ago  he  took 
some  milk,  and  that  some  time  before  he  had  a  small  quantity  of  scraped 
meat.  On  auscultating  in  the  infrasternal  depression  we  can  not  hear 
any  deglutition-murmurs,  neither  a  first  nor  a  second  sound  being  pres- 
ent ;  but  by  listening  at  the  neck,  after  swallowing,  we  can  distinctly  hear 
the  fiuid  passing  down  without  being  able  to  appreciate  the  so-called 
"  stenosis-murmur,"  which  sounds  as  though  the  fluid  were  being  forced 
through  a  narrow  spot. 

Consequently  there  can  be  no  doubt  that  we  have  to  deal  with 
a  case  of  stenosis  of  the  cardia,  and  a  consecutive  dilatation  of  the 
(Bsophagus  ahove  this.  This  is  proved  not  only  by  the  examination 
with  the  sound  and  the  negative  results  of  all  exploratory  proced- 
ures directed  toward  the  stomach,  but  also  by  the  results  of  the 
chemical  examination. 


SOUNDING  OP  THE  CESOPHAGUS.  Y7 

The  distance  to  the  cardia  from  the  incisor  teeth  naturally  va- 
ries with  the  height  of  the  individual.  The  average  figure  is  esti- 
mated to  be  40  centimetres  [16  inches],  of  which  15  centimetres 
[6  inches]  include  the  distance  from  the  incisors  to  the  commence- 
ment of  the  oesophagus,  5  centimetres  [2  inches]  belong  to  its  cervi- 
cal, 17  centimetres  [6f  inches]  to  its  thoracic,  and  3  centimetres  [1^ 
inches]  to  its  abdominal  portion.  I  have  repeatedly  found  much 
greater  measurements,  as  high  as  -46  centimetres  [18f  inches]  in  toto. 
According  to  this,  the  44  centimetres  [I'Zf  inches],  for  which  dis- 
tance we  introduced  the  sound  from  the  incisors,  would  just  repre- 
sent the  length  of  the  oesophagus,  plus  the  mouth  and  throat,  in  a 
large  man  like  our  patient,  and  its  point  would  be  arrested  just 
above  the  cardia. 

At  this  place  I  shall  introduce  a  few  practical  points  about  the 
sounding  of  the  aesophagus. 

For  sounding  the  oesophagus  we  must  use  either  the  oesophageal 
sponge-probang,  rigid  sounds,  or  the  tube.  The  first  consists  of  a 
small  sponge,  about  the  size  of  a  hazel-nut,  fastened  to  a  straight 
or  slightly  curved  piece  of  whalebone.  With  this,  if  it  be  long 
enough — although,  as  a  rule,  the  instrument-makers  make  them 
much  too  short — the  oesophagus  is  swept  out,  as  it  were,  the  jDres- 
ence  of  any  obstruction  established,  and  possibly  shreds  of  tissue 
caught  in  the  meshes  of  the  sponge  and  brought  up  for  examina- 
tion. The  objection  to  the  instrument  is  that  in  patients  who  have 
a  narrow  entrance  to  the  oesophagus,  or  in  whom  there  is  marked 
irritability  of  the  constrictors,  considerable  force  is  needed  both  to 
introduce  and  to  remove  it  from  the  oesophagus,  for  at  times  it  is 
caught  so  tightly  immediately  at  the  entrance  (or,  in  the  other 
sense,  the  exit)  of  the  oesophagus,  or  at  a  certain  spot  behind  the 
larynx,*  that  an  inexperienced  person  could  be  led  thereby  to 
assume  an  abnormal  obstruction.  It  stands  to  reason  that  the  sponge 
is  not  to  be  dry,  but  that  it  must  be  moistened  and  always  thor- 
oughly cleansed  and  disinfected  before  it  is  used.     I  have  already 


*  Waldeyer.  Beitragezur  norraalen  und  vergleichenden  Anatomie  des  Pharynx 
mit  besonderer  Beziehung  auf  den  Sehlingweg.  Sitzungsb.  d.  Akad.  d.  Wissensch. 
zu  Berlin,  Physik.-math.  Klasse,  1886,  25  Febr. 


78  DISEASES  OF   THE   STOMACH. 

given  you  the  necessary  information  concerning  tlie  technique  of 
this  manipulation  on  page  8  of  the  first  lecture. 

The  best  oesophageal  sounds  are  made  of  prepared  catgut.  They 
must  be  flexible,  and  are  either  bluntly  pointed  or  provided  with  a 
tapering  knobbed  extremity.  As  advantageous  as  the  latter  seems 
to  be  in  order  to  work  its  way  through  a  stenosed  or  constricted 
spot,  just  so  undesirable  do  these  sounds  prove,  for  the  thinned  por- 
tion above  the  knob  is  soon  bent  on  repeated  use.  I  never  employ 
sounds  which  contain  a  wire  or  which  consist  only  of  whalebone, 
because  they  are  too  hard,  or  in  the  physical  sense  too  elastic,  and 
on  account  of  the  danger  of  perforation.  We  must  have  the  various 
sizes  of  sounds  at  hand,  preferably  ISTos.  13  to  30  of  Charriere's 
scale,  so  that  if  necessary  we  can  employ  progressively  smaller 
sounds.  It  is  to  be  regretted  that  the  thinner  the  instrument  is,  the 
more  do  we  lose  the  necessary  feeling  of  resistance ;  and  when  the 
sounds  have  only  the  diameter  of  a  quill  it  is  impossible  to  decide 
whether  in  a  given  case  we  are  pushing  the  instrument  on,  or 
whether  it  has  been  bent  or  twisted  like  a  corkscrew.  For  this  rea- 
son alone  the  oesophageal  or  stomach  tubes  are  preferable  to  the 
sounds,  from  which  they  diflier  by  being  hollow  and  having  an  eye- 
let on  either  side  of  the  tube  above  its  blunt  extremity.  While  they 
serve  the  same  purpose  for  sounding,  we  can  readily  tell  by  pouring 
in  fluid  whether  we  have  passed  the  constriction  or  are  still  above 
it,  and  this  even  with  the  smallest  tubes.  But  they  also  possess  the 
advantage  that  after  we  have  succeeded  in  passing  one  through  the 
oesophagus  (no  matter  what  the  disease  may  be),  w^e  can  immediately 
thereafter  pour  nourishing  fluids  into  the  stomach.  This  is  an  ad- 
vantage which  is  not  to  be  underestimated,  for  it  is  often  a  matter 
of  accident  whether  the  tube  glides  into  the  stomach  or  not.  For 
this  reason,  in  sounding  the  oesophagus  I  invariably  employ  the  so- 
called  feeding-tube,  with  a  funnel-shaped  enlargement  at  the  upper 
end,  so  that  if  necessary  I  can  at  once  introduce  fluid. 

Finally,  the  fenestrated  tubes  have  another  advantage  in  that  the 
edges  of  the  openings  not  infrequently  shave  off  particles  of  tissue 
which  would  not  have  been  caught  in  the  sponge.  As  a  matter  of 
course,  the  soft-rubber  tubes  are  not  applicable  for  sounding  the 
oesophagus  or  possibly  for  overcoming  strictures,  since  a  certain 


SOUNDING  OP  THE  (ESOPHAGUS. 


79 


amount  of  rigidity  is  requisite  for  that  purpose.  Yet  tlie  soft  tube, 
open  at  the  lower  end,  has  several  times  proved  itself  of  advantage  to 
me  in  cases  of  cancerous  stricture,  since  particles  of  the  neoplasm  were 
forced  into  it  by  the  patient's  gagging  or  coughing  when  the  tube 
was  introduced  as  deeply  as  possible,  and  the  point  consequently 
either  impinged  upon  the  tumor  or  insinuated  itself  into  the  funnel- 
like constriction.  Such  particles  had  not  become  adherent  at  previ- 
ous attempts  either  to  the  sponge  or  to  the  rigid  fenestrated  sound. 

After  this  digression  let  us  return  to  the  further  consideration  of 
the  results  of  the  examination 
of  our  patient.  Aside  from  the 
negative  result  of  the  physical 
examination,  I  consider  the 
chemical  examination  of  the 
masses  brought  up  of  the  great- 
er importance  because  its  re- 
sults may  have  enough  weight 
to  turn  the  scale  in  a  doubtful 
case.  The  following  case  may 
serve  as  a  proof  of  this  : 

Mrs.  S.,  sixty-two  years  old, 
suflPered  with  carcinoma  of  the 
stomach  and  liver.  On  passing 
the  sound,  she  showed  great  simi- 
larity to  the  case  we  are  consider- 
ing in  regard  to  the  resistance  met 
by  the  instrument.  Here,  too,  the 
sound  struck  an  impassable  bar- 
rier at  the  level  of  the  ensiform 
j)rocess.  Immediately  above  this 
I  had  the  unmistakable  impres- 
sion of  having  passed  a  constricted 
spot,  and  after  this  was  overcome 

there  followed  the  hissing  sound  of  air  escaping  from  the  stomach.  The 
cause  of  this  resistance  offered  to  the  sound  remained  doubtful  during  life. 

The  autopsy  showed  that  a  very  large  tumor  growing  up  from  the 
retroperiton£eum  had  encircled  the  cardia  and  had  lifted  the  fundus  of 
the  stomach  horizontally  upward,  so  that  to  a  certain  extent  two  divisions 
of  the  stomach  were  formed,  one  horizontal  and  one  vertical.  The  sound 
impinged  upon  the  bottom  of  the  former.  In  order  that  the  condition 
may  be  more  thoroughly  comprehended,  the  accompanying  illustrations 
(Figs.  7  and  8),  made  by  me  at  the  autopsy,  are  here  inserted. 


Fig.  7.— Stomach  of  Mrs.  S.,  died  June  30, 1887. 
Side  view,  to  show  the-  cardia  and  cul-de- 
sac  surrounded  bv  the  new  growth. 


80 


DISEASES  OF  THE  STOMACH. 


Similar  conditions  might  also  be  present  in  our  case,  or,  as 
Quincke  *  has  shown,  a  kind  of  valve  may  be  formed  by  an  ulcer  of 
the  oesophagus,  which  would  prevent  the  introduction  of  the  sound. 


Fig.  8. — Stomach  of  Mrs.  S.    Front  view,  showing  cancerous  nodules  on  the  anterior  sur- 
face of  the  liver,  the  head  of  the  pancreas,  the  cardia,  and  the  retroperitoneal  tissues. 

But  while  in  that  case  the  masses  which  came  up  through  the  tube 
always  contained  pepsin  and  several  times  also  peptone,  while  they 
repeatedly  showed  a  yellowish-green  color  due  to  admixture  with 
bile,  our  case  is  absolutely  negative  in  this  regard.  This  is  proof 
positive  that  they  do  not  come  from  the  cavity  of  the  stomach. 

If  according  to  these  facts  there  can  be  no  doubt  about  the  exist- 
ence of  stricture  of  the  cardia,  its  nature  and  cause  are  not  less  posi- 
tively to  be  established. 

As  I  have  already  said  at  the  commencement  of  this  lecture, 
closure  of  the  cardia  may  be  caused  in  two  ways:  (1)  By  spastic 
cont/raction,  and  (2)  hy  cicatricial  tissue  or  neojplasm  situated  either 
within  or  without  the  cardia.  The  former,  the  spastic  contractions, 
which  are  always  the  result  of  a  neurosis  or  of  a  reflex,  consequently 

*  Quincke.    Klappenbildung  an  der  Cardia.    Deutsch.  Arch,  fur  klin.  Med., 

1883,  Bd.  31,  S.  408. 


SPASMODIC  STRICTURE  OF   CARDIA.  81 

of  a,  purely  functional  nature,  can  in  general  be  easily  distinguished 
from  the  firm  closure  of  the  cardia  by  the  following  points  :  The 
contractions  are  frequently  intermittent,  sometimes  being  entirely 
absent,  and  at  other  times  appearing  only  feebly — i.  e.,  with  com- 
plete integrity  of  the  power  of  deglutition.  They  occur  in  parox- 
ysms due  to  mental  disturbances,  exhausting  attacks,'^  neuralgias,t 
palpitation  of  the  heart,  etc.  Direct  or  more  remote  irritating  fac- 
tors, such  as  oesophagitis  and  gastritis,  even  gastric  carcinoma,  me- 
tritis, pregnancy,  and  irritation  due  to  worms,  can  also  produce 
spasm  of  the  oesophagus.  It  occurs  in  neuropathic  persons  suffer- 
ing with  nervousness,  neurasthenia,  and  hysteria,  and  on  observation 
they  can  be  recognized  as  specially  well-marked  features  of  a  general 
nervous  disease.  Furthermore,  such  obstructions  can  be  overcome 
by  a  thick  sound,  either  immediately  or  after  it  has  been  kept  in  the 
oesophagus  for  a  short  time.  This  procedure  will  also  succeed  under 
chloroform.  Naturally,  this  could  not  be  done  where  the  stricture  is 
organic.  The  larger  the  caliber  of  the  sound,  the  more  readily  can 
spasmodic  contractions  be  overcome. 

It  is  well  known  that  spastic  strictures  may  appear  throughout 
the  whole  length  of  the  oesophagus,  and  at  times  may  become  so 
marked  as  to  sinmlate  the  symptoms  of  hydrophobia. ;{:  They  may 
exist  for  months  and  even  years  without  specially  influencing  the 
nutrition  of  the  patient ;  thus  we  meet  with  well-fed  ladies  who  say 
that  they  "  are  unable  to  force  down  a  morsel."  Yet  such  spasms 
may  lead  to  the  most  severe  disturbances  of  nutrition  and  may  even 
result  in  death.*     The  seat  of  the  spasm  is  shown  by  the  distance  to 

*  Carron.  Observation  sur  une  suspension  de  la  deglutition  pendant  plus  de 
deux  jours  produit  par  un  emetique  violent  chez  un  homme  atteint  d'une  dyspepsie 
rhumatique.  J.  gener.  de  med.,  chirurg.  et  pharni.  Paris,  1811,  pp.  58-62.  A  re- 
markable case,  entitled  Spasmodic  Inability  of  Deglutition  caused  by  Mercurial 
Unction,  is  reported  in  the  Med.  Obs.  Soc.  Phys.,  London,  1784,  which  I  was  unable 
to  procure. 

f  Coin  reports  A  Case  of  Spasm  of  the  (Esophagus  and  Air-passages  from  Dorso- 
intercostal  Neuralgia.  This  was  mistaken  for  an  organic  stricture.  Charleston 
Med.  J.  Rev.,  1851,  pp.  199-205. 

X  J.  Barnes.  A  Singular  Case  of  Spasmodic  Disease,  simulating  Hydrophobia. 
Amer.  Med.  Record,  1822,  pp.  650-652. 

*  H.  Power.  On  a  Case  of  Spasmodic  Stricture  of  the  CEsophagus  terminating 
fatally.  The  Lancet,  1866,  i.  No.  10.  The  patient,  refusing  an  operation,  died  of 
inanition.    Nothing  found  at  the  autopsy. 


82  DISEASES  OF   THE  STOMACH. 

which  the  sound  can  be  introduced  until  it  reaches  the  constricted 
spot,  unless,  as  I  saw  in  one  case,  the  sound  invariably  passes  into 
the  stomach  with  ease,  and  the  spasm  appears  only  on  eating — i.  e., 
swallowing  solid  or  fluid  foods,  and  then  not  at  once,  but  only  later- 
The  patients  are  frequently  able  to  overcome  the  spasm  by  various 
manipulations,  as  can  be  seen  in  the  following  history  of  such  a 
case :  * 

Miss  M.,  from  New  York,  August  15,  1885.  Age  thirty -three.  Well 
nourished  ;  appetite  good ;  bowels  regular.  Asserts  that,  on  swallowing, 
the  food,  both  liquid  and  solid,  lies  above  the  stomach.  She  is  able  to 
take  a  small  plate  of  soup  and  a  corresponding  quantity  of  other  nourish- 
ment, but  then  she  must  make  extra  exertions  to  force  the  mass  down 
into  the  stomach. 

Stomach  in  the  normal  position,  somewhat  distended.  Normal  on  per- 
cussion and  palpation.  Patient  eats  two  cakes  and  drinks  a  glass  of  water, 
but  the  murmurs  of  deglutition  could  not  be  heard.  After  repeated  deep 
inspirations  and  simultaneous  efforts  at  swallowing  she  forces  air  into  the 
gullet,  and  then  at  the  same  time  we  can  hear  a  very  pronounced  and 
ioud  sound  as  if  something  were  being  squirted  through  (Durchspritz- 
gerdiisch).  The  stomach  tube  is  arrested  at  the  cardia  ;  the  English  sound 
enters  the  stomach  after  overcoming  a  certain  mild  resistance. 

In  this  case,  consequently,  in  which  there  were  no  manifest 
hysterical  or  neuropathic  factors  to  account  for  the  spasm,  it 
could  be  overcome,  and  the  general  nutrition  of  the  patient  was 
correspondingly  but  slightly  influenced.  Nevertheless,  her  con- 
dition was  extremely  painful  and  unpleasant,  for  at  her  meals  she 
was  forced  to  leave  the  table  as  soon  as  she  had  taken  a  couple 
of  morsels,  in  order  to  perform  her  "  swallowing  gjannastics,"  and 
she  was  thus  naturally  debarred  from  all  kinds  of  society  except 
that  of  her  most  intimate  friends.  In  this  case  there  was  evi- 
dently spasm  of  the  cardia,  due  to  its  hypersensibility,  a  condition 
of  which  I  shall  sj)eak  again  under  the  neuroses  of  the  stomach. 

Organic  Strictures. — Strictures  of  the  cardia  or  of  the  lowest  por- 
tion of  the  oesophagus,  due  to  cicatricial  tissue,  are  the  usual  results 
of  the  action  upon  these  parts  of  caustic  or  corrosive  substances 
such  as  lyes  and  acids.  Yirchow  has  called  attention  to  the  fact 
that  there  is  here  a  point  of  predilection  for  the  action  of  these  sub- 

*  This  case  has  since  been  reported  in  detail  in  the  Berliner  klin.  Wochenschr., 
,  No.  3,  by  Dr.  Meltzer,  of  New  York. 


ORGANIC  STRICTURES  OF   CARDIA,  83 

stances,  and  this  is  easily  understood,  since  the  investigations  of 
Kronecker  and  Meltzer  have  shown  that  the  swallowed  mass  re- 
mains immediately  above  the  cardia  after  having  been  hurried 
through  the  oesophagus.  Rare  causes  of  cicatricial  stricture,  in 
fact,  uncommon  occurrences,  are  syphilitic  and  tubercular  ulcers 
and  tdcris  rotundum  oesopliagi.  According  to  Quincke,*  the  latter 
can  also  lead  to  narrowing  of  the  gullet,  and  is  usually  situated 
just  above  the  cardia. 

I  have  a  drawing  of  such  an  ulcer  from  the  portfolio  of  the  late 
Prof,  von  Frerichs,  w'hich  was  situated  just  above  the  cardia,  and 
which  resulted  in  a  marked  cicatricial  contraction  and  consecutive 
dilatation  of  the  oesophagus. 

The  cicatricial  tissue  is  firm,  does  not  ulcerate,  and  has  a  marked 
contractile  tendency,  so  that  such  constrictions,  if  left  to  themselves, 
rapidly  reach  a  high  degree,  and  may  even  lead  to  cord-like  fibrous 
obliteration  of  the  oesophagus.  As  a  rule,  it  is  easy  to  overcome 
the  stricture  with  a  sound  of  the  proper  size,  because  pockets  and 
projections  in  which  the  point  of  the  sound  might  be  caught  are  in 
general  not  to  be  found  in  the  smooth  cicatricial  tissue  {vide  the 
case  of  Quincke  cited  above).  The  history,  and  the  negative  result 
of  the  examination  for  cancer,  are  of  diagnostic  import. 

The  neoplasms  which  lead  to  constriction  of  the  cardia  resolve 
themselves  into  those  wdiich  exert  pressure  from  Avithout,  and  those 
which  are  situated  in  the  tissues  of  the  digestive  tract,  and  which 
grow  from  its  wall  into  the  lumen. 

Among  the  former  class  we  find  tumors,  abscesses,  and  firm 
swellings  of  a  carcinomatous,  sarcomatous,  or  fibrous  nature,  wdiich 
develop  in  the  tissues  of  the  mediastinum  or  retroperitouEeum ;  or 
they  may  be  glands  which  have  undergone  carcinomatous  or  scrofu- 
lous degeneration.  There  is  normally  a  little  group  of  glands  close 
above  the  foramen  oesophageum  of  the  diaphragm. f  Or  they  may 
be  osseous  or  periosteal  tumors  growing  from  the  vertebral  col- 
umn ;  or,  finally,  aneurisms  of  the  large  arteries.     Such  conditions, 

*  H.  Quincke.     Ulcus  oesophagi  ex  digestione.     Deutsch.  Arch,  fiir  klin.  Med., 
Bd.  24,  S.  72. 

f  Vide  Thaddeus.     Dysphagie  durch  Schwellung  der  Bronchialdriisen.     Berl. 
klin.  Wochenschr.,  1889,  No.  36. 
7 


84  DISEASES  OP  THE  STOMACH. 

as  a  rule,  are  readily  recognized  by  a  careful  study  of  the  history 
and  all  the  accompanying  symptoms.  It  would  lead  me  too  far  to 
take  up  the  particulars  of  the  differential  diagnosis  here,  but  I 
will  not  omit  cautioning  you  particularly  against  the  use  of  rigid 
sounds  or  tubes  in  the  examination  of  such  cases.  Under  such 
circumstances,  even  with  careful  manipulation,  the  danger  of  a 
possible  perforation  is  never  to  be  entirely  excluded,  and  is  always 
to  be  avoided,  especially  since  soft  tubes  will  often  serve  our  pur- 
pose if  we  wish  to  discover  whether  the  passage  into  the  stom- 
ach is  patent,  and  since  the  obstruction  caused  by  these  processes  is 
never,  as  a  rule,  very  marked,  Abercrombie  reported  such  a  per- 
foration. As  a  warning,  Yon  Frerichs  in  his  lectures  always  cited 
a  case  in  which  an  unrecognized  aneurism  of  the  thoracic  aorta 
was  the  cause  of  obstruction  to  deglutition,  A  rigid  sound  was 
introduced,  and  the  point  perforated  the  wall  of  the  oesophagus 
adjacent  to  the  aneurism,  which  had  been  thinned  by  it,  and  also 
the  aneurismal  sac,  thus  producing  fatal  hsemorrhage.  I  myself 
saw  the  following  case  : 

A  gentleman,  forty-five  years  of  age,  had  suffered  for  some  time  with 
la.ncinating'  pains  coming  on  in  attacks  and  located  in  tlie  mediastinal 
region  back  of  the  ensiform  cartilage.  At  the  acme  of  the  attack  the 
pain  was  so  unendurable  that  it  could  only  be  allayed  by  large  injections 
of  morphine.  He  acquired  the  morphine  habit  and  had  subjected  himself 
to  treatment  for  this.  For  a  time  the  paroxysms  were  less  severe,  but 
they  then  reappeared  as  intense  as  before.  Inasmuch  as  there  was  no 
objective  reason  for  these  pains,  the  cause  was  suspected  to  be  a  x^sychical 
one,  hysteria;  syphilis  was  also  thought  of,  although  syphilitic  new- 
growths  usually  cause  very  little  or  no  pain,  and  antisyphilitic  treatment 
was  without  result.  Then  later  on  there  appeared  difficulties  connected 
with  eating,  the  food  seeming  to  remain  above  the  stomach;  his  appetite, 
which  had  been  capricious  for  a  long  time,  now  disappeared  entirely,  and 
he  lost  considerable  strength.  Fever  was  never  present.  At  times  he 
expectorated  muco-pus  containing  no  elastic  fibers — this  was  before  the 
era  of  bacilli.  Sounding  the  cBsophagus  was  suggested.  Percussion 
showed  the  heart  dullness  to  be  abnormally  increased,  extending  on  the 
right  to  the  right  margin  of  the  sternum,  above  and  on  the  left  to  the 
lower  border  of  the  third  rib;  no  murmurs;  radial  pulse  regulai*,  equal  on 
both  sides ;  the  back  showed  no  dullness  or  sound  of  any  kind,  except 
signs  of  a  slight  catarrh.  In  view  of  this,  and  of  the  attacks  of  pain, 
and  the  remaining  general  conditions,  I  suspected  a  mediastinal  tumor, 
perhaps  an  aneurism,  and  therefore  advised  against  the  introduction  of 
the  sound. 

Two  nights  afterward  the  patient  had  a  terrific  hsemorrhage,  consisting 


DANGERS  OF  RIGID  STOMACH-TUBES.  85 

of  pure  blood,  not  frothy,  which  "  seemed  as  though  it  gushed  from  the 
mouth,"  and  he  died  in  a  few  moments.  Although  an  autopsy  was  not 
allowed,  there  can  be  no  doubt  that  a  large  blood-vessel  had  perforated  into 
the  oesophagus,  and  it  is  equally  certain  that  the  blame  would  rightly  or 
wrongly  have  been  ascribed  to  a  pi'evious  sounding  had  it  been  undertaken. 
A  similar  case  was  reported  by  me  at  the  meeting  of  the  Berlin  Medi- 
cal Society  on  June  18, 1890.*  A  man  who  was  suspected  of  having  a  can- 
cer of  the  stomach  presented  himself  to  have  the  stomach-tube  introduced 
in  oixler  to  obtain  some  of  the  gastric  contents  for  examination.  No  tumor 
could  be  felt,  yet  he  was  emaciated  and  cachectic.  Heart  and  heart-sounds 
normal.  While  the  patient  was  introducing  the  tube  himself,  which  he 
did  without  any  exertion,  he  suddenly  fell  back,  became  pale  and  cya- 
notic, and  died  within  a  few  minutes.  There  was  no  haematemesis,  nor 
was  there  any  blood  on  the  tube.  During  the  last  few  moments  of  life  a 
rapid  increase  in  the  area  of  cardiac  dullness  and  a  loud  friction-sound 
over  the  heart  could  be  made  out.  The  diagnosis  made  was  ha^matoperi- 
cardium,  resulting  from  rupture  or  perforation  of  an  aneurism.  The  au- 
topsy revealed  the  presence  of  a  dissecting  aneurism  at  the  beginning  of 
the  ascending  aorta  just  above  the  aortic  valves  and  still  within  the  peri- 
cardium, just  where  the  latter  is  reflected.  At  this  spot  the  wall  of  the 
aneurism  was  torn,  and  it  was  here  that  the  blood  had  entered  the  peri- 
cardial cavity.  The  stomach  and  oesophagus  were  absolutely  intact  and 
were  free  from  any  neoplasm.  It  must  remain  an  open  question  whether 
this  was  merely  a  coincidence,  or  whether  the  introduction  of  the  tube 
and  the  consequent  increase  in  the  intrathoracic  pressure  had  caused  the 
rupture  of  the  aneuiism.  However,  the  latter  supposition  is  very  im- 
probable, for  the  reason  that,  according  to  physiological  laws,  the  blood- 
pressure  (an  increase  of  the  pressure  on  the  internal  wall  of  the  aneurism 
or  aorta  which  alone  could  cause  the  rupture)  is  not  increased  by  the 
introduction  of  the  stomach-tube. 

Just  such  cases  warn  us  to  be  cautions  under  all  circumstances 
in  making  an  examination  with  the  sound,  and  you  ought  not  to 
think  that  I  take  unnecessary  trouble  in  a-koays  assuring  myself  in 
the  most  careful  manner  of  the  condition  of  the  heart  and  its  ad- 
nexa  before  I  explore  the  oesophagus  or  stomach  w^th  the  sound. 

Constricting  neoplasms  of  the  cardia  are  always  of  a  carci- 
nomatous nature,  and  are  very  rarely  indeed  limited  exclusively  to 
the  orifice  of  the  stomach.  As  a  rule,  they  spread  from  above — 
the  lower  section  of  the  oesophagus ;  or  from  below — the  cardiac 
portion  of  the  stomach. 

Rokitanski  f  states  that  a  special  characteristic  of  cancer  of  the 

*  Ewald.     Ein  Fall  von  Aneursyma  dissecans.     Berl.  klin.  Woehenschr.,  1890, 
p.  694. 

f  Rokitanski.    Handbuch  der  speciellen  pathologischen  Anatomie.    Bd.  ii,  S.  205. 


86 


DISEASES  OP  THE  STOMACH. 


cardia  is  tliat  it  always  lias  tlie  tendency  to  involve  the  oisopliagus, 
thus  contrasting  with  cancer  of  the  pylorus.  As  opposed  to  this 
assertion,  Brinton  *  cites  two  cases  of  sharply  locahzed  cancer  of  the 
cardia,  and  in  consideration  of  the  rarer  appearance,  on  the  whole, 
of  malignant  growths  in  the  region  of  the  cardia,  he  believes  that 
both  cancers  of  the  pylorus  and  of  the  cardia  appear  locahzed  with 
about  equal  frequency— that  is,  one  case  to  fifteen  in  which  it 
spreads.  Disregarding  my  own  relatively  small  personal  experi- 
ence, which,  by  the  way,  agrees  entirely  with  Kokitansld's  views,  I 
can  find  but  few  recorded  cases  of  isolated  cancer  of  the  cardia — 
two  cases  of  epithelial  cancer  of  the  size  of  an  egg,  described  by 
Hanot,t  which  were  limited  exactly  to  the  cardia — and  also  through 
the  kindness  of  Prof.  Yirchow,  I  saw  only  one  more  case  in  the 
splendid  collection  of  our  [Berlin]  pathological  institute,  of  which 
I  append  a  drawing  made  by  myself  (Fig.  9).  Should  we  wish  to 
regard  the  neoplasms  which  strictly  involve  only  the  circular 
muscular  ring  of  the  cardia  as  localized  cancers,  we  can  easily 
see  that  the  tendency  for  them  to  spread  has  already  been  pro- 
vided for  in  the  anatomical  arrangement  ;  for  the  muscular 
layer,  as  is  well  known,  is  made  up  of  semicircular  and  cross- 
ing fibers  which  spread  from  the  cardiac  to  the  fundal  zone  of  the 
stomach. 

As  a  rule,  the  cause  of  these  tumors  is  not  to  be  discovered,  and 
the  hereditary  factor  is  far  oftener  absent  than  present.  I  shall 
again  treat  of  this  subject— heredity — in  the  general  discussion  of 
carcinoma  of  the  stomach.  I  must  not  forget  to  mention  that  two 
of  my  patients  positively  ascribed  their  trouble  to  traumatisms. 
One  of  them,  a  lawyer,  traced  it  to  a  fall  in  which  he  hurt  his  chest ; 
and  the  other,  a  farmer,  while  at  work  in  the  field,  suddenly  experi- 
enced a  sharp  pain  within  his  chest,  and  since  then  he  claims  that 
the  disease  developed.  In  both  there  was  cancer  of  the  cardia.  I 
scarcely  need  say  that  such  statements  can  only  be  accepted  with  the 
greatest  caution.  The  well-known  necessity  of  man,  especially  a 
sick  man,  of  finding  a  cause,  frequently  leads  him  to  confound  the 

*  Brinton.  Lectures  on  the  Diseases  of  the  Stomach.  Second  edition,  London-, 
1864,  p.  227. 

f  Hanot.     Arch,  gener.  de  Med.,  October,  1881. 


CANCER   OP   CARDIA. 


87 


^ost  lioG  or  the  simul  cum  with  the  ijropter  Jioc.  But  since  it  has 
been  proved  that  traumatisms  may  give  rise  to  carcinomata,  it  ap- 
pears to  me  that  this,  to  which  as  far  as  I  know  no  attention  has 
been  paid,  is  worth  mentioning. 


Fig.  9. — Localized  cancer  of  cardiac  orifice  of  stomach.    (From  Berlin  Pathological  Institute.) 
a,  CBsophagus  ;  6,  localized  cancer  of  cardia ;  f,  cavity  of  stomach. 

I  shall  consider   the   nature  of   carcinomatous   tumors  of   the 
stomach  and  their  diagnosis  in  a  later  lecture  {vide  Lecture  Y). 


88  DISEASES   OP   THE  STOMACH. 

Let  us  now  return  to  our  case  of  to-day. 

Among  the  many  causes  which  we  nmst  consider  as  producing 
the  stenosis  in  our  patient,  one  may  be  at  once  excluded,  and  that  is 
cicatricial  stricture  of  the  oesophagus.  He  has  never  swallowed  cor- 
rosive fluids  ;  he  does  not  remember  having  taken  food  hot  enough 
to  cause  the  well-known  burning  sensation  at  any  part  of  the  digest- 
ive tract  down  to  and  into  the  stomach,  although  his  occupation, 
that  of  a  restaurateur,  would  offer  a  certain  inducement  therefor. 
He  has  never  experienced  pressure  or  a  blow  on  the  chest ;  no  sign 
points  to  disease  of  the  organs  of  resjDiration  or  circulation  or  of  the 
bones.  He  has  had  no  fever.  There  can  be  no  thought  of  a  spastic 
contraction,  judging  from  the  history  and  the  objective  symptoms. 
We  can  exclude  a  diverticulum — i.  e.,  a  saccular,  partial  dilatation 
of  the  oesophageal  wall  without  any  narrowing — because  the  diver- 
ticula are  always  situated  in  the  upper  portion,  chiefly  the  upper 
third,  of  the  oesophagus,  and  never  extend  as  low  down  as  the 
cardia. 

Thus  by  exclusion  we  would  arrive  at  the  assumption  of  a  car- 
cinomatous stricture  of  the  cardia.  It  is  true  that  positive  evidence 
is  entirely  lacking ;  yet  its  absence,  above  all  the  absence  of  en- 
larged glands,  the  deficient  proof  of  carcinomatous  tissue-elements, 
the  freedom  from  all  pain,  and  the  relatively  moderate  loss  of 
muscular  tissue  and  of  strength,  do  not  oppose  it. 

Only  a  short  time  ago  I  saw  a  case,  almost  the  exact  counterpart 
of  the  present  one,  differing  from  it  only  in  that  loss  of  flesh  and 
strength  had  advanced  much  further.  Here,  too,  there  was  no  posi- 
tive evidence  of  cancer,  either  from  the  history  or  on  physical  ex- 
amination. At  times  the  stricture  would  admit  small  sounds,  but, 
as  a  rule,  they  could  not  be  passed.  We  made  an  artificial  gastric 
fistula  in  this  patient,  and  at  the  operation  we  had  the  oj)portunity 
of  palpating  the  stomach  and  the  surrounding  viscera  through  the 
abdominal  wound.  We  could  very  plainly  palpate  a  tumor  in  the 
region  of  the  cardia  beneath  the  diaphragm,  which  felt  to  be  about 
as  wide  as  a  finger,  somewhat  fiattened,  and  inclosing  the  cardiac 
opening  like  a  ring.  Several  weeks  after  the  operation  the  patient 
died  while  absent  from  Berlin,  and,  although  it  is  to  be  regretted 
that  an  autopsy  was  not  held,  yet  the  diagnosis  of  cancer  in  this  case 


DILATATION   OF   THE   CESOPHAGUS.  89 

is  as  firmly  established  as  tlioiigh  it  had  been  made  bj  ocular  in- 
spection. 

Thus  also  in  our  patient,  as  so  frequently  occurs  in  making  a 
diagnosis,  the  proper  estimation  of  negative  data  is  nearly  as  im- 
portant as  the  positive  results  of  examination,  and  we  are  justified 
in  making  a  diagnosis  of  carcinomatous  stricture  of  the  cardia. 
Whether  it  lies  within  or  without  the  lumen  is  a  question  which  we 
must  leave  unsettled. 

There  still  remains  a  condition  to  be  discussed  which  is  nearly 
always  a  result  of  stricture  of  the  oesophagus  or  the  cardia  of  long  du- 
ration, and  that  is  dilatation  of  tlie  oesophagus  above  the  constricted 
spot.  But  since  a  prolonged  reaction  of  the  narrowed  jDortion 
upon  the  parts  above  is  necessary  for  their  formation,  we  can  easily 
understand  the  rare  occurrence  of  such  secondary  dilatations  in  cases 
of  carcinomatous  stricture,  which,  as  a  rule,  cause  death  too  rapidly. 

Saccular  dilatations  of  the  gullet  have  always  been  subdivided 
into  the pi'essure  and  the  traction  dwerticula  and  simple  ectasis. 

The  first  two  are  partial  dilatations  of  the  periphery  of  the 
oesophageal  wall,  which  appear  as  blind  appendices  attached  to  the 
otherwise  normally  sized  tube,  and  which  when  moderately  well 
developed  and  in  a  filled  condition  may  appear  on  the  surface  of  the 
body  as  circumscribed  projections.  They  have  no  place  in  the  pres- 
ent discussion,  since,  as  has  already  been  mentioned,  they  occur  in 
the  upper  two  thirds  of  the  oesophagus ;  in  fact,  the  former  are  situ- 
ated chiefly  at  the  boundary  between  the  throat  and  the  oesophagus. 
Thus  I  will  only  consider  the  last  form.  Dilatations  situated  above 
a  constricted  spot,  as  a  rule,  tend  to  involve  the  whole  circumference 
of  the  gullet,  and,  after  existing  for  some  time,  to  cause  complete 
atrophy  of  the  mucous  membrane,  while  the  muscularis  is  thinned 
and  its  fibers  separated  into  wide  meshes.  By  this  I  do  not  mean  to 
say  that  the  dilatation  may  not  develop  more  in  a  certain  direction 
and  in  this  way  gradually  lead  to  the  formation  of  a  true  pocket. 
For  this  purpose  there  is  needed  only  a  somewhat  greater  yielding 
of  the  oesophageal  muscle-fibers  to  the  pressure  of  masses  of  food. 
Such  a  case  was  observed  by  Xicoladoni  '-^  in  a  four-year-old  girl, 

*  Nicoladoni.     Wiener  med.  Wochenschr.,  1877,  Xo,  25. 


90  DISEASES  OF  THE  STOMACH. 

wlio  liad  a  stricture  of  the  oesophagus  due  to  corrosion.  The  strict- 
ure was  8  centimetres  [3-^  inches]  long,  and  above  it  the  oesophagus 
was  irregularly  bellied  out  for  a  distance  of  2^  centimetres  [1  inch], 
chiefly  on  the  anterior  wall  and  to  the  left,  so  that  there  existed  a 
saccular  dilatation  which  was  sharply  shut  off  from  the  stricture, 
and  in  which  one  could  easily  introduce  the  entire  last  plialanx 
of  the  forefinger.  Under  such  conditions  —  that  is,  when  the 
stricture  is  not  immediately  above  the  cardia,  but  is  situated 
higher  up  in  the  gullet — partial  dilatations  may  give  the  first  im- 
petus to  the  formation  of  a  diverticulum,  for  which  there  is  no 
room  immediately  above  the  diaphragm.  However,  the  dilata- 
tion existing  in  our  case  must  have  reached  a  considerable  size, 
otherwise  it  would  not  be  conceivable  how  it  could  hold  100  c.  c. 
[f  §  iij  3  ij]  and  over.  Naturally  this  can  only  take  place  at  the 
expense  of  the  neighboring  viscera  by  compressing  or  displacing 
them. 

"Wheatley  Hart  *  describes  the  case  of  a  woman,  fifty-eight  years 
old,  who  had  for  twenty  years  suffered  with  dysphagia,  connected 
with  frequent  vomiting,  and  who  gradually  died  of  marasmus.  The 
autopsy  showed  the  following  :  The  stomach,  the  mucous  membrane 
of  which  showed  no  abnormalities,  was  small  and  its  mouth  so  nar- 
row that  the  little  finger  could  only  be  introduced  with  difficulty ; 
but  there  was  neither  thickening  nor  hardening  of  the  tissue  at  this 
place.  Above  this  the  cesophagus  was  enormously  dilated,  so  that 
on  the  right  side  of  the  spine  it  lay  in  the  hollow  of  the  ribs,  where 
it  was  fairly  bent  at  a  right  angle  and  directed  toward  the  foramen 
diaphragmaticum.  On  its  removal  it  looked  like  a  second  stomach, 
and  could  hold  Y50  grammes  [  ^  xxv]  of  fluid.  The  muscularis  was 
greatly  hypertrophied.  Hart  believes  that  it  was  originally  attached 
to  the  lungs  and  pericardium,  but  that  it  was  afterward  separated  by 
a  retracting  pleuritis  and  mediastinitis,  since  both  processes  were 
found  markedly  developed. 

Spasmodic  contractions  of  the  oesophagus  of  long  standing  may 
also  cause  dilatation  of  the  portion  of  the  gullet  lying  above  them. 

<; 

*  Wheatley  Hart.     Autopsy  on  a  Case  of  Prolonged  Vomiting.     Lancet,  1883, 
ii,  p.  456. 


TREATMENT.  91 

Leichtenstern  *  has  reported  a  well-marked  example  of  tliis  in  a 
patient  who  had  suffered  for  seven  years  from  obstinate  hysterical 
vomiting. 

A  case  wdiicli  I  have  reported  elsewhere  f  was  remarkable  for 
the  fact  that  the  dilatation  existed  not  above,  but  below  the  site  of 
the  carcinomatous  stricture ;  the  latter  was  located  at  nearly  the 
middle  of  the  oesophagus.  It  was  evident  that  this  was  due  to  a 
fatty  degeneration  and  an  accompanying  atrophy  of  the  muscular 
fibers  in  the  lower  section  of  the  gullet ;  consequently  this  portion  of 
the  tube  lost  its  contractile  power  and  became  dilated  by  the  swal- 
lowed masses,  wdiich,  as  shown  by  the  experiments  of  Kronecker 
and  Meltzer,  normally  accumulate  above  the  cardia  and  are  forced 
through  the  latter  by  the  contractions  of  the  oesophagus. 

One  of  my  patients,  in  whom  there  was  a  condition  entirely 
analogous  to  that  existing  in  the  case  under  discussion,  complained 
of  severe  dyspnoea  as  soon  as  he  made  any  extra  demands  upon  his 
respiratory  organs,  even  in  walking  from  one  room  to  another  a 
little  faster  than  usual  or  on  going  up-stairs.  The  patient  whom  you 
see  to-day  was  so  short  of  breath  the  first  time  he  visited  me  that  at 
the  first  glance  I  took  him  to  be  suffering  with  pulmonary  or  cardiac 
disease.  This  condition  may  be  primarily  ascribed  to  the  general 
weakness  of  the  patient,  but  it  can  in  part  be  referred  to  purely  me- 
chanical causes — to  compression  of  the  lungs,  and  possible  displace- 
ment of  the  heart. 

The  treatment  of  our  case  is  clearly  indicated.  Inasmuch  as  the 
stricture  is  entirely  or  practically  impassable,  and  since  internal  medi- 
cation, even  if  we  possessed  specific  remedies,  would  thus  be  of  no 
avail,  and  since  mechanical  dilatation  is  impossible,  there  remain 
only  rectal  alimentation  and  the  production  of  a  gastric  fistula.  Al- 
though rectal  alimentation  is  very  valuable  for  a  short  while,  it  is 
not  effective  for  long  periods  of  time,  and  therefore  if  the  entrance 
to  the  stomach  is  closed  to  all  kinds  of  food  or  nourishing  materials 
it  is  to  be  combined  with  gastrostomy.     We  shall  perform  this  oper- 


*  Leichtenstern.  Enorme  sackartige  Erweiterung  des  Oesophagus  ohne  me- 
chanische  Stenose  desselben  in  einera  Palle  von  siebenjahrigem  hysterischen  Er- 
breehen.     Deutsch.  med.  Wochenschr.,  1891,  No.  4. 

f  Ewald.     Berl.  klin.  Wochenschr.,  1889,  No.  23. 


92  DISEASES  OF  THE  STOMACH. 

ation  in  our  case,  and,  if  j)ossible,  we  shall  attempt  bloodless  dilata- 
tion of  the  constricted  portion,  working  from  within  the  stomach. 

The  patient  presented  to  you  on  the  3d  of  this  month,  on  whom 
gastrostomy  was  to  be  performed  because  of  our  diagnosis  of  can- 
cerous stricture  of  the  cardia,  was  operated  on  in  my  presence  by 
Prof.  Sonnenburg  five  days  later.  Reserving  the  remarks  concern- 
ing the  operation  kindly  placed  at  my  disposal  by  Prof.  Sonnenburg 
for  the  end  of  this  lecture,  I  wish  now  to  tell  you  that  we  j^alpated 
the  stomach  after  the  abdominal  cavity  was  opened,  but  were  un- 
able to  recognize  any  abnormity. 

Two  days  later,  when  the  fistula  had  been  established,  it  was  seen 
that  with  the  exception  of  some  mucus  the  stomach  was  empty. 
This  mucus  had  a  neutral  reaction  on  strips  of  litmus-paper  which 
were  introduced. 

For  the  first  three  days  after  the  formation  of  the  fistula  the  condition 
of  the  patient  was. excellent.  He  complained  only  of  a  feeling'  of  press- 
ure, but  retained  the  nutrient  enemata  given  to  him  and  the  soup  poured 
in  through  the  fistula.  On  the  fourth  day  he  began  to  cough  a  little  and 
to  bring  up  slightly  fluid,  greenish-yellow  sputum,  which  contained  small, 
whitish  particles  about  the  size  of  a  grain  of  sand  or  the  head  of  a  pin. 
The  cough  increased  in  frequency  and  severity,  chiefly  at  night,  and  could 
not  be  relieved  by  subcutaneous  injections  of  morphine.  A  penetrating 
odor  from  the  mouth  became  noticeable,  and  the  evening  temperature  rose 
to  39'2°  C  [102'5°  F.].  Examination  of  the  sputum  revealed  numerous  pus- 
cells,  free  nuclei,  bacteria,  and  masses  of  cocci,  but  no  tubercle  bacilli  and 
no  elastic  fibers.  The  minute  particles  mentioned  above  consisted  of  large 
numbers  of  short,  rod-shaped  bacilli,  so  that  they  almost  represented  a  pure 
culture.  An  ineffectual  attempt  was  made  to  check  the  putrid  decomposi- 
tion by  giving  the  patient  capsules  of  salicylic  acid  to  swallow  and  by 
washing  out  the  oesophagus  with  a  solution  of  the  san^e  drug.  Dullness 
and  bronchial  breathing  appeared  over  the  lower  portions  of  both  lungs 
posteriorly.  Elastic  fibers  were  now  found  in  the  sputum,  and  a  diagno- 
sis of  double  pleuro-pneumonia  due  to  perforation  or  swallowing  was 
made.  The  fever  continued,  the  patient's  strength  rapidly  failed,  and  he 
died  on  the  eighth  day  after  the  operation  in  a  mildly  somnolent  state. 

The  autopsy  which  I  made  revealed  the  following : 

Fundus  of  the  stomach  lies  in  the  hollow  of  the  diaphragm.  It  meas- 
ures 12  centimetres  [4|  inches]  in  its  widest  portion,  and  30  centimetres 
[12  inches]  from  the  pylorus  to  tbe  cardia.  The  organ  when  cut  open  has 
a  transverse  diameter  of  19  centimetres  [7|  inches].  The  opening  of  the 
fistula  is  6  centimeti-es  [2f  inches]  above  and  to  the  right  of  the  ring  of  the  • 


STENOSIS   OP   CARDIA.  93 

pylorus.  Its  edges  are  puffed  up,  so  that  the  mucous  membrane  lies  quite 
smoothly  over  the  muscularis  toward  the  outer  side  From  without  the 
pylorus  feels  swollen  and  thickened.  On  cutting  oi^en  the  viscus  we  see 
that  this  is  caused  by  a  trabecular  thickening  of  the  submucous  connect- 
ive tissue,  while  the  muscularis  and  serosa  are  not  involved. 

Even  from  without  we  can  see  that  the  oesophagus  above  the  cardia  is 
converted  by  a  dilatation  measuring  6  to  7  centimetres  [2|  to  2^  inches]  into 
a  hard,  sausage-like  mass.  On  introducing  a  thin  glass  rod  it  either  enters 
a  pocket,  in  which  it  is  arrested,  or  it  passes  through  a  narrow  canal 
into  the  stomach.  Water  poured  in  from  above  slowly  flows  into  the 
stomach  after  first  having  rapidly  filled  the  oesophagus.  The  latter  is 
widened  above  the  tumor,  so  that  at  a  distance  of  5  centimetres  [2  inches] 
from  the  upper  margin  it  has  a  diameter  of  6  centimetres  [2|  inches] ;  then 
it  gradually  becomes  narrower,  and,  13  centimetres  [5\  inches]  higher  up, 
is  only  3  centimetres  [1|-  inches]  wide.  Opening  the  oesophagus,  we  see 
that  the  growth  commences  exactly  at  the  cardia  and  that  the  incision 
has  separated  it  into  a  larger  (right)  and  smaller  (left)  ovoid  portion  with 
only  a  very  narrow  canal — admitting  a  thin  pencil — between  them,  which 
is  further  marked  by  warty  polypoid  excrescences.  The  growth  is  so  fri- 
able that  the  right  side  tears  apart  lengthwise,  thus  opening  an  empty 
cavity  or  cleft  lined  with  a  greenish-gray,  fairly  firm  membrane  (Fig.  10). 
Under  the  surface  of  the  mucous  membrane  of  the  oesophagus  are  single 
small  punctate  nodules,  appearing  faintly  white  through  the  mucous 
membrane,  the  epithelium  of  which  is  desquamated  in  shreds  as  though  it 
had  been  corroded.  The  same  condition  exists  immediately  below  the 
tumor,  where  it  passes  on  to  the  mucous  m.embrane  of  the  stomach.  The 
latter  membrane  is  smooth  at  the  fundus  and  of  a  pretty  pink  color.  In 
the  remaining  portions  it  is  thrown  into  very  many  folds  and  is  more  of  a 
slate  color.  No  punctate  haemorrhages  or  suggillations.  The  left  side  of 
the  oesophagus  corresponding  to  the  expansion  of  the  tumor  is  attached  to 
the  mediastinum  and  the  pulmonic  pleura  by  a  recent  adhesive  inflam- 
mation. A  lymphatic  gland,  situated  above  and  to  the  left  of  the  dia- 
phragm, is  slightly  tumefied,  and  on  section  shows  commencing  punctate 
suppuration. 

The  lower  lobes  of  both  lungs  are  swollen,  of  a  marked  reddish-brown 
color,  and  are  absolutely  non  aerated.  The  upijer  lobes  and  the  middle 
one  of  the  right  lung  are  aerated,  and  the  pleura  covering  the  two  lower 
lobes  shows  a  recent  slight  fibrinous  deposit.  "We  further  find  sharply 
circumscribed  round  spots  of  a  light  greenish-yellow  color  like  pus,  chiefiy 
at  the  base  of  the  right  lung.  They  are  less  numerous  on  the  posterior 
surface  of  the  lower  lobes  of  the  right  and  left  lungs.  Their  size  varies 
from  that  of  a  lentil  to  that  of  a  pea.  On  cutting  into  them  we  discover 
that  they  correspond  to  httle  hollows  with  a  membranous  lining  and 
filled  with  a  smeary,  greenish-yellow  mass  having  a  penetrating  and  most 
offensive  odor.  A  bronchus  or  bronchiole  can  be  traced  to  each  hollow. 
The  mucous  membrane  of  the  bronchi  is  dark  bluish  red  in  color,  like 
satin,  swollen,  and  filled  with  quantities  of  frothy,  blood-streaked  pus. 

All  the  other  organs  are  normal. 

The  small  intestines  are  unusually  firmly  contracted,  so  that  they  are 
scarcely  the  size  of  a  finger. 


DISEASES  OF  THE  STOMACH. 


Fig.  10. — Carcinoma  of  03Sophagus  just  above  the  cardia.     Mr.  P.  died  Aug.  3,  1887. 
a,  oesophagus,  J,  cardia,  c,  cavity  of  stomach. 


TREATMENT   OF  STRICTURES  OP   CARDIA.  95 

A  fresh  particle  of  the  tumor  scraped  from  its  surface  shows  the  most 
varied  forms  of  cylindrical  and  pavement  epithelium,  round  cells  with 
large  nuclei,  and  masses  of  cocci.  Microscopic  examination  of  the  hard- 
ened tumor  reveals  an  epithelioma  extending  down  to  the  serosa,  with 
portions  of  its  elements  undei'going  degeneration. 

In  this  record  of  the  autopsy  the  patency  of  the  stricture  estab- 
lished post  mortem  does  not  seem  to  correspond  to  the  complete 
closure  existing  during  life.  If  we  consider,  tliough,  that  the  tissues, 
losing  their  turgescence,  shrink  after  death,  w^e  can  easily  explain 
how  during  life  the  narrow  canal  was  completely  displaced  and  oc- 
cluded between  the  masses  of  the  grow^th.  At  any  rate,  the  opera- 
tion was  not  only  fidly  indicated,  but  it  would  have  offered  the  best 
chances  for  the  patient  had  not  the  gangi-enous  aspiration  pneu- 
monia ^ScKl'iickjpnewmonie^  intercurred.  This  is  an  accident,  pre- 
vention of  which  lies  beyond  our  power.  A  lady  with  carcinoma  of 
the  oesophagus,  on  whom  gastrostomy  was  performed  also  by  Prof. 
Sonnenburg,  was  in  as  good  condition  five  months  after  the  opera- 
tion as  the  circumstances  could  possibly  permit,  in  spite  of  the  fact 
that  five  years  previously  her  right  breast  had  been  amputated  and 
the  right  arm  disarticulated  subsequently  on  account  of  cancer  of 
the  breast.  She  died  finally  of  a  fresh  metastasis  which  developed 
in  the  right  pleura. 

Let  us  finish  the  history  of  our  case  w^ith  a  discussion  of  the 
Treatment  of  Strictures  of  the  Cardia. — In  all  organic  strictures 
of  the  oesophagus  situated  at  the  cardia  we  can  only  expect  help 
from  operative  procedures.  Nobody  can  believe  that  we  can  obtain 
any  results  with  internal  medication,  the  so-called  resolvent  or  altera- 
tive drugs  of  a  therapy  which  is  not  so  very  ancient,  mercurials  or 
iodine,  or  even  with  the  bighly  praised  condurango.  We  can  only 
attempt  the  bloodless  dilatation  of  the  stricture  by  means  of  sounds, 
and  where  this  is  impossible  we  must  perform  gastrostomy.  Dilata- 
tion of  the  stenosis  with  bougies  necessarily  presupposes  at  least  a 
partial  penetration  of  the  instrument  into  the  constricted  portion. 
As  a  rule,  this  will  succeed  at  first  if  the  stricture  be  a  simple  incom- 
plete one  without  secondary  dilatation  of  the  parts  higher  up.  For 
this  we  should  always  nse  the  largest  sounds  possible — at  least,  we 
should  always  attempt  to  introduce  the  larger  ones.     The  thinner 


98  DISEASES  OF  THE  STOMACH. 

the  sound,  tlie  greater  the  danger  tliat  its  fine  point  will  be  canglit  in 
the  inequalities  of  the  constricted  spot  or  in  pockets  due  to  second- 
ary dilatation,  even  when  these  pockets  are  so  small  that  a  heavier 
sound  would  glide  past  them.  In  this,  as  always  occurs  under  such 
circumstances,  accident  may  play  an  important  role  y  at  one  time  we 
may  succeed  in  passing  the  sound,  and  at  another  it  bends  at  its 
point.  I  have  frequently  found  it  to  be  advantageous  to  allow  the 
patients  to  force  down  the  sounds  themselves  to  a  certain  extent  by 
ordering  them  to  make  repeated  efforts  at  swallowing.  It  may  then 
glide  into  the  proper  path,  and  can  be  pushed  on  by  slight  pressure 
from  above. 

The  introduction  of  sounds  too  frequently  or  too  rapidly  re- 
peated is  to  be  guarded  against,  I  have  seen  a  sound  (ISTo.  20,  Char- 
riere)  pass  through  a  stricture  with  comparative  ease,  but  it  would 
not  do  so  on  the  fourth  or  fifth  day,  since  a  marked  swelling  or  a 
rapid  growth  of  the  affected  parts  had  undoubtedly  been  caused  by 
the  irritation  of  the  sound.  Mackenzie  *  has  also  called  attention  to 
the  same  fact.  We  allow  the  sound  to  remain  in  sitti  for  from  three 
to  five  minutes,  and  pass  from  the  smaller  to  the  larger  numbers.  It 
is  disagreeable  to  a  great  many  patients  who  permit  the  sound  to 
pass  easily  to  retain  it  for  this  length  of  time,  principally  on  account 
of  the  copious  secretion  of  saliva.  In  such  cases  I  usually  first  give 
a  subcutaneous  injection  of  3  milligrammes  {^-^  grain]  of  atropine 
with  5  milligrammes  \j^  grain]  of  morphine.  The  salivation  then 
ceases  entirely  or  does  not  appear  at  all,  while  the  morphine  in- 
creases the  tolerance  of  the  patient.  Instead  of  the  English  sounds 
we  can  use  a  staff  of  whalebone  with  olive-shaped  ivory  points, 
which  can  be  unscrewed  and  changed  to  larger  or  smaller  sizes  as 
the  occasion  may  demand. 

Thin  English  sounds  with  pyriform  extremities  are  also  made. 
At  Frerichs'  clinic  we  used  long,  smooth  instruments  of  whalebone 
of  various  sizes.  If  the  stricture  is  not  too  marked,  we  can  also  use  a 
soft-rubber  oesophageal  tube  of  the  proper  caliber,  which  is  intro- 
duced into  the  stomach  and  allowed  to  remain  there  for  a  while. 


*  Morell  Mackenzie.     Die  Krankheiten  des  Halses  und  der  Nase.    Uebersetzung 
von  F.  Semoii.     Berlin,  1884,  S.  130  u.  185. 


THE  PERMANENT  CANULA.  97 

The  patients  tolerate  this  better  than  keeping  a  stiff  sound  in  j)lace, 
because  they  can  close  their  mouths,  and  they  do  not  have  the  trouble- 
some flow  of  saliva ;  moreover,  it  also  seems  to  create  less  irritation 
at  the  affected  spot. 

Finally,  as  early  as  1843,  Switzer  in  Copenhagen  proposed  the 
use  of  a  permanent  canula,  which  was  used  later  on  by  Krishaber, 
Mackenzie,  Symonds,  and  recently  by  Leyden  and  Renvers,"  in  the 
form  of  a  kind  of  catheter  a  deineui^e.  A  slightly  conical  tube,  oval 
on  section,  made  of  hard  rubber,  or  a  caoutchouc  catheter,  to  which 
two  strong  silk  cords  are  attached,  is  introduced  into  the  constricted 
part  by  means  of  a  whalebone  guide  supplied  with  a  proper  obtura- 
tor and  left  there  after  the  withdrawal  of  the  guide.  The  cords 
hang  from  the  mouth  and  are  wound  around  the  ear,  or  they  may  be 
carried  through  the  nose.  If  the  tube  does  not  become  clogged,  it  is 
allowed  to  remain  in  place  as  long  as  fourteen  days.  It  is  then  re- 
moved and  a  new  one  substituted.  This  procedure  naturally  pre- 
supposes a  certain  size  of  the  stricture,  since  canulas  smaller  than  a 
large  pencil  can  not  be  introduced  well  unless,  like  Mackenziejf  we 
care  to  forcibly  thrust  the  catheter  through  the  stricture,  which, 
granting  that  it  be  possible,  is  by  no  means  advisable.  Leyden  and 
Kenvers,  in  two  cases  in  which  they  diagnosticated  oesophageal  can- 
cer, had  the  good  fortune  to  obtain  excellent  results  by  means  of  a 
permanent  canula — i.  e.,  increase  in  the  patient's  weight  for  a  con- 
siderable time.  In  three  or  four  cases  in  which  the  existence  of  car- 
cinoma of  the  oesophagus  was  proved  by  autopsy,  I  found  that  the 
patients  could  tolerate  the  canula  only  for  a  comparatively  short 
time,  but  that  I  could  produce  a  decided  transient  relief  by  it.  Son- 
nenburg  :|:  properly  says  that  but  few  cases  are  lit  for  this  procedure, 
which  can  easily  lead  to  rapid  growth  of  the  cancer,  the  occurrence 
of  sudden  haemorrhages,  necrosis,  perforations,  etc.  When  the 
stricture  is  situated  at  the  spot  which  interests  us  at  present — the 

*  E.  Leyden  and  Renvers.  Ueber  die  Behandlung  carcinomatoser  Oesophagus- 
strictur.  Deutsch.  med.  Woehenschr.,  1887,  No.  50.  [Also,  Renvers.  Die  Be- 
handlung der  Oesophagnsstricturen  mittelst  Dauerkaniilen.  Zeitschrift  f.  klin. 
Med.,  Bd.  xiii,  S.  499.— Tr.] 

f  Loc.  cit. 

X  E.  Sonnenburg.  Beitrage  zur  Gastrostomie.  Berl.  klin.  Wochenschrift,  1888, 
No.  1. 


98  DISEASES  OP  THE  STOMACH. 

deepest  portion  of  the  oesopliagiis- — the  tube  must  reach  into  the 
stomach.  It  is  doubtful  whether  this  is  possible  without  causing 
persistent  irritation.  At  any  rate,  it  has  not  yet  been  attempted. 
The  same  may  be  said  of  Gersung's  new  and  complicated  "  perma- 
nent sound  for  the  oesophagus."  * 

The  difficulties  of  introducing  the  instrument  grow  projiortion- 
ately  with  the  increase  in  the  consecutive  dilatation  of  the  gullet 
or  of  the  possible  excrescences  and  pockets  of  the  constricting 
growth.  At  times  it  would  appear  that  in  cases  in  which  a  diverticu- 
lum had  also  formed  it  might  be  possible  to  pass  the  sound  beyond 
the  pocket  and  into  the  stomach  by  giving  it  a  certain  direction ; 
thus  several  authors  give  rules  for  this  purpose.  In  my  opinion,  if 
the  obstruction  is  just  above  the  cardia,  this  is  entirely  illusory, 
None  of  the  sounds  which  we  are  able  to  introduce  into  the  oesopha- 
gus possesses  rigidity  enough  to  enable  us  to  give  its  point  a  definite 
direction  after  it  has  reached  the  level  of  the  lower  portion  of  the 
oesophagus.  You  can  easily  convince  yourselves  of  this  on  a  corpse 
or  a  suitably  suspended  preparation  in  which  the  stomach  and  oesoph- 
agus are  preserved  entire  and  in  continuity.  Keither  have  I  been 
able  to  discover  any  particular  advantage  in  a  special  position  of  the 
patient  according  to  the  supposed  site  of  the  dilatation.  "VTe  must 
admit  that  in  an  actual  case  it  is  a  matter  of  luck  whether  the  intro- 
duction of  the  sound  is  successful  or  not.  However,  that  the  post- 
ure of  the  patient  may  come  into  consideration  during  the  passage 
of  tlie  masses  swallowed  is  shown  by  the  following  very  excellent 
example  : 

On  the  19th  of  July  I  was  consulted  by  B.,  a  farmer  from  Steiidal.  He 
had  been  examined  by  several  physicians  because  of  a  group  of  symptoms 
which  pointed  to  a  diverticulum  of  the  oesophagus.  By  some  his  condi- 
tion was  said  to  be  a  diverticulum,  while  others  considered  it  a  nervous 
spasm  of  the  gullet.  The  patient's  nutrition  and  general  condition  ap- 
peared little  changed.  He  could  attend  to  his  business  as  well  as  ever, 
but  he  felt  a  slight  loss  of  sti'ength,  and  as  he  had  read  about  the  pernicious 
results  of  oesophageal  diverticula,  he  was  in  doubt  whether  or  not  to  give 
up  his  property,  retn-e,  make  all  arrangements  in  conformity  therewith, 
and  await  the  threatening  ^?iaZe.  The  difficulties  in  swallowing  had  late- 
ly increased  very  slowly ;  subjectively  they  manifested  themselves  only  in 
occasional  regurgitation  of  the  food.     In  reference  to  this  the  patient  had 

*  Wiener  med.  Wochenschr.,  1887,  No.  43. 


USE  OF  SOUNDS.  99 

observed  that  at  times  portions  of  "  regurgitated  "  food  had  been  eaten  not 
at  the  last,  but  at  a  previous  meal.  The  sound  was  caught  in  a  deeply  sit- 
uated sac  after  being  introduced  40  centimetres  [16  inches]  from  the  in- 
cisors. This  made  the  patient  cough,  when  he  brought  up  unchanged 
coffee  which  he  had  taken  three  hours  before.*  It  contained  no  free  acid. 
No  deglutition-murmurs  could  be  heard  with  the  patient  in  the  erect  post- 
ure. On  the  other  hand,  however,  when  he  lay  down,  a  second  sound 
could  be  heard  very  distinctly  twelve  seconds  after  swallowing.  This  was 
confirmed  by  frequent  repetition.  Thus  the  entrance  of  food  into  the 
stomach  was  not  entirely  prevented,  but,  as  the  sound  proved,  was  possible 
under  special  conditions.  In  spite  of  this,  even  on  a  second  trial,  I  was 
unable  to  pass  a  sound  into  the  stomach,  whether  the  patient  was  erect 
or  recumbent.  It  was  plainly  to  be  seen  that  in  this  case  conditions  were 
created  by  the  dorsal  decubitus  which  rendered  the  passage  of  the  swal- 
lowed mass  a  possibility.  We  can  therefore  assume  that  the  dilatation — 
for  with  this  we  had  to  deal,  without  any  doubt — was  situated  anteriorly, 
so  that  when  the  patient  lay  on  his  back  it  collapsed  to  a  certain  extent, 
and  thus  did  not  form  a  '"trap."  At  any  rate,  the  diverticulum  was  a 
small  one,  for.  after  the  patient  had  been  directed  to  drink  a  whole  glass- 
ful of  water,  the  deglutition-murmur  could  be  heard  when  he  was  stand- 
ing. This  proved  that  the  sacculation  was  now  filled,  and  that  it  neither 
caught  any  further  masses  which  were  swallowed  nor  prevented  their  en- 
trance into  the  stomach.  Thus  a  sufficient  degree  of  nutrition  was  still 
possible,  and  in  this  way  only  could  I  explain  the  relatively  good  condi- 
tion of  the  patient,  which  had  manifestly  been  the  reason  why  others  as- 
sumed the  presence  not  of  stricture  or  of  a  diverticular  formation,  but  of 
a  spastic  condition  of  the  oesophagus,  especially  if,  as  is  very  possible,  they 
could  occasionally  introduce  a  sound  into  the  stomach  without  any 
trouble.  It  is  to  be  regretted  that  circumstances  did  not  permit  a  subse- 
quent examination  of  the  patient ;  nevertheless,  the  facts  just  laid  before 
you  were  amply  sufficient  to  exclude  a  spastic  contractiu'e  and  to  estab- 
lish the  diagnosis  of  a  diverticulum.  As  for  treatment,  I  advised  the 
patient  to  abstain  from  all  sounding  for  the  present,  for  if  the  sound  took 
a  false  direction  this  might  give  rise  to  unpleasant  signs  of  irritation,  per- 
haps to  mechanical  enlargement  of  the  diverticulum;  further,  only  to 
permit  it  when  his  difficulties  had  become  more  marked,  especially  when 
the  feeling  of  obstruction  on  swallowing  appeared ;  and,  finally,  to  assume 
a  recumbent  position  as  much  as  possible  when  eating. 

Especially  good  results  from  the  use  of  tlie  sound  are  met  with 
in  cases  of  cicatricial  strictures  if  the  patience  of  both  patient  and 
physician  holds  out,  and,  in  case  the  stricture  has  become  more  pa- 
tent, their  use  is  not  discontinued  too  soon.  Even  if  the  constriction 
seems  to  be  sufficiently  dilated  the  use  of  the  sounds  should  not  be 


*  In  a  case  of  Delia  Chiaje  (cited  by  Mackenzie)  cofPee  was  regurgitated  as  late  as 
five  days  after  it  had  been  swallowed,  without  being  in  the  least  changed. 


100  DISEASES  OP  THE  STOMACH. 

stopped  for  some  time,  for  the  contractile  tendency  of  cicatricial  tis- 
sue is  very  great  and  constantly  recurring. 

For  a  long  time  after  the  campaign  of  1870  I  treated  a  young  physician 
who,  returning  to  camp  extremely  fatigued  one  day,  had  received  a  burn 
and  consecutive  stricture  of  the  oesophagus  by  attempting  to  drink  from  a 
canteen  apparently  filled  with  water.  The  vessel — whether  purposely  or 
not,  we  will  leave  unsettled — was  filled  with  pure  sulphuric  acid!  He 
could  only  spit  out  a  portion  of  the  first  hasty  swallow,  and  thus  the  poor 
fellow  not  only  received  a  severe  burn  of  the  oesophagus,  but  also  had  to 
suffer  from  a  consecutive  stricture.  In  this  patient  I  could  follow  the 
tendency  to  constantly  recurring  narrowing  of  the  affected  spot  for  years. 

'Now  that  the  true  poisons  are  used  more  frequently  for  purposes 
of  suicide,  we  do  not  have  the  opportunities  which  we  formerly  had 
to  study  these  cicatricial  strictures  and  their  course  when  it  was 
still  the  fashion  for  maid-servants  to  poison  themselves  with  "  oleum  " 
(impure  sulphuric  acid) ;  for,  queer  as  it  may  seem,  fashion  has  a 
decided  influence  even  upon  this  melancholy  procedure !  I  regret 
that  I  do  not  possess  any  statistical  records  of  that  period,  so  that  I 
can  only  say  from  my  general  impression,  in  accordance  with  the 
views  of  other  authors,  that  cicatricial  strictures  offer  a  favorable 
prognosis  unless  they  reach  a  certain  degree  of  constriction  ;  but  as 
soon  as  we  have  to  deal  with  advanced  stages,  sounding  leaves  us  in 
the  lurch  exactly  as  it  does  in  cancerous  constrictions.  The  latter 
especially  always  offer  unfavorable  prospects.  We  may  indeed  suc- 
ceed in  making  the  canal  more  patent  for  a  time,  but  we  can  not 
permanently  contend  with  the  progressive  new  growth.  Again,  we 
must  not  be  surprised  or  deceive  ourselves  with  false  hopes  if,  espe- 
cially toward  the  end  of  life,  the  stricture  suddenly  seems  to  become 
more  patent  or  to  have  disappeared  entirely.  This  is  a  result  of 
ulceration,  and  is  always  to  be  regarded  as  a  bad  omen. 

For  most  strictures  nothing  remains  but  gastrostomy  (to  o-rSjjia, 
the  mouth),  the  establishment  of  a  gastric  fistula,  first  proposed  by 
Egeberg  in  183T  and  performed  by  Sedillot  in  1849.  The  tortures 
which  the  patients  suffer  from  their  disease,  the  slow  starvation 
which  is  their  lot,  are  indeed  so  frightful  that  we  must  attempt  re- 
lief even  if  we  know  it  will  only  be  transient.  It  is  to  be  regretted 
that  as  yet  the  operation  is  performed  too  late  in  most  cases.  The 
patients  are  very  slow  to  consent  to  a  procedure  about  which,  even 


GASTROSTOMY.  101 

though  very  nnjiistlj,  there  still  hangs  a  nimbus  of  its  being  a  won- 
derful operation.  They  only  submit  from  extreme  necessity,  and  thus 
the  best  time,  that  of  a  relatively  good  general  condition,  passes  by. 
It  is  true  that  recently  there  has  been  a  decided  i)rogress  in  this  direc- 
tion, and  consequently  the  results  of  the  operation  have  progressive- 
ly become  more  favorable.  In  1864  Mackenzie  collected  67  cases 
of  gastrostomy  in  carcinoma  of  the  oesophagus,  12  of  cicatricial 
stricture,  and  2  of  syphilitic  stricture,  and  found  that  the  longest 
duration  of  life  amounted  to  from  5^  to  Y|-  months.  Then  in  1885 
Zesas  *  collected  129  cases  of  cancer,  31  of  cicatricial  stricture,  and 
2  cases  of  syphilis,  and  estimated  16*2  per  cent  of  cures  (?)  in  the  first, 
55  per  cent  of  cures  in  the  cicatricial  strictures,  and  among  the 
deaths,  IY'2  per  cent  who  survived  the  operation  for  twelve  months. 
If  we  select  only  those  operations  which  have  been  performed  since 
the  inauguration  of  antisepsis  (131),  we  get  19*5  per  cent  [cancer] 
and  68'Y  per  cent  [cicatricial  stenosis]. 

Gastrostomy,  to-day,  is  in  itself  so  free  of  danger  that  it  is  indi- 
cated in  every  case  as  soon  as  the  diagnosis  of  a  non-dilatable  strict- 
ure of  the  cardia,  with  or  without  consecutive  dilatation,  is  estab- 
lished. iN'othing  else  can  save  the  patient  from  the  starvation  which 
threatens  him.  The  chances  for  success  naturally  depend  upon  the 
character  of  the  constriction,  and  the  earlier  the  operation  is  under- 
taken and  the  less  the  general  condition  of  the  patient  is  depressed  the 
better  are  the  prospects.  That  this  operation  can  not  save  life  need 
scarcely  be  mentioned.  At  any  rate,  if  no  abnormal  intercurrent  at- 
tacks appear,  life  is  prolonged  and  death  in  cases  of  carcinoma  is  due 
to  the  more  or  less  rapid  course  of  cancerous  intoxication  and  not 'to 
starvation.  Even  the  psychical  influence  of  the  operation  on  the 
patients,  the  advantages  of  which  you  can  readily  understand,  is  not 
to  be  underestimated,  and  the  reproach  made  by  a  j^atient  to  Prof. 
Kocher,  that  "he  had  unnecessarily  made  a  hole  in  his  stomach," 
may  well  be  regarded  as  exceptional.  Among  five  patients  to  whom 
I  proposed  the  operation,  only  one  refused  to  undergo  it,  and  he  was 
a  Russian  general,  who  preferred  death  in  St.  Petersburg  to  an  opera- 
tion in  Berlin. 

*  Gr.  Zesas.    Die  Gastrostomie  und  ihre  Resultate.    Arch.  1  klinische  Chirurgie, 
Bd.  33,  S.  188. 


102  DISEASES  OP  THE  STOMACH. 

For  tlie  following  statement  regarding  the  technique  of  the  opera- 
tion I  am  indebted  to  the  kindness  of  mj  colleague,  Prof.  Sonnen- 
burg,  who  has  operated  upon  two  of  mj  patients  'during  the  past 
year,  and  who  has  lately  published  his  experiences  :  * 

"First  of  all,  in  gastrostomy  for  cancerous  stricture  it  is  not 
easy  to  determine  the  position  of  the  stomach,  %vhich  is  markedly 
shrunken  on  account  of  the  insufficient  supply  of  food.  The  best 
incision  is  one  5  to  6  centimetres  [2  to  2-|-  inches]  long,  beginning 
below  the  xiphoid  cartilage  and  running  parallel  to  and  a  finger's 
breadth  away  from  the  free  border  of  the  ribs  on  the  left  side,  ex- 
tending with  a  slight  concavity  downward  to  about  the  ninth  rib. 
After  separation  of  the  skin,  fasciae,  and  muscles,  and  the  most  care- 
ful cliecking  of  hsemorrhage,  the  peritoneeum  is  opened  and  fixed, 
best  by  means  of  two  looped  cords.  On  making  traction  upon  the 
loops  the  omentum  and  intestines  can  be  seen  in  the  depths  of  the 
wound.  If  we  have  chosen  an  incision  nearer  the  mid-line,  we  can 
see  the  left  lobe  of  the  liver  ;  but  this  is  usually  only  a  hindrance  in 
our  attempts  to  find  the  stomach.  The  best  way  to  find  this  viscus 
is  by  endeavoring  to  introduce  the  hand  to  the  region  of  the  cardia 
and  to  pull  forward  that  portion  of  the  intestinal  tract  lying  there. 
In  most  cases,  especially  when  the  stomach  is  very  much  contracted, 
some  difficulty  may  be  experienced  in  distinguishing  between  the 
stomach  and  the  transverse  colon ;  but  we  can  recognize  the  colon 
by  its  muscular  bands  and  the  stomach  by  the  sweep  of  its  lower 
curvature  and  the  vessels  which  enter  there.  But  in  a  very  atrophic 
condition,  and  especially  if  the  viscus  is  with  difficulty  drawn  for- 
ward, these  otherwise  readily  recognizable  landmarks  may  be  very 
poorly  marked.  There  have  been  cases  in  which  the  colon  has  been 
fixed  in  the  wound  instead  of  the  stomach,  and  this  in  spite  of 
great  care. — Our  attention  now  in  fastening  and  sewing  the  stomach 
is  to  be  directed  to  getting  the  opening  in  the  organ  as  near  as  pos- 
sible to  the  cardia,  because  then  only  is  the  efficient  nourishment  of 
the  patient  possible  later  on  ;  for  the  nearer  this  opening  lies  to  the 
pylorus  the  more  readily  will  the  food  introduced  into  the  stomach 
on  being  propelled  forward  flow  out  of  the  fistula,  and  thus  the 

*  Loc.  cit. 


TECHNIQUE  OP  GASTROSTOMY.  103 

nourishment  of  the  patient  become  impossible.  A  small  portion  of 
tlie  gastric  wall,  situated  as  high  as  possible,  is  then  drawn  forward 
in  the  shape  of  a  ridge  and  attached  all  around  to  the  parietal  peri- 
tonseum  by  stitches  which  only  include  the  serosa ;  then  the  peri- 
tonaeum itself  is  stitched  to  the  fasciae  and  muscles — not  to  the  skin. 
If  it  be  at  all  possible,  the  stomach  is  left  unopened  for  several  days, 
the  wound  being  tamponed  with  iodoform  gauze  until  union  has 
taken  place.  After  two  or  at  most  three  days  we  may  exclude  the 
danger  of  the  occurrence  of  peritonitis  from  the  entrance  of  stomach- 
contents  into  the  abdominal  cavity.  The  best  way  to  open  the  stom- 
ach itself  is  with  a  pointed  thermo-cautery.  The  opening  need  only 
be  very  small  at  first,  for  it  enlarges  itself  in  a  short  time.  The  in- 
troduction of  fluid  food  is  best  performed  at  first  by  means  of  a  thin 
oesophageal  tube. 

"  In  order  to  find  the  stomach  more  readily,  the  introduction  of 
a  thin  sound  with  an  easily  distensible  bulb  attached  to  the  lower 
end  has  been  recommended.  This  naturally  can  only  be  thought  of 
in  case  the  stricture  is  not  too  marked.  The  introduction  of  a  Seid- 
litz  powder  into  the  stomach  to  distend  the  organ  by  the  formation 
of  gas  could  hardly  ever  be  accomplished  in  practice. 

"  Many  suggestions  and  experiments  have  been  made  as  to  the 
introduction  of  nourishment.  We  can  get  along,  however,  with 
very  simple  methods.  As  has  already  been  mentioned,  we  may  at 
first  use  a  thin  oesophageal  tul)e  for  this  purpose,  the  opening  of  the 
fistula  being  closed  in  the  intervals  with  a  rubber  or  wooden  stop- 
per. Later  a  thin  short  silver  canula  may  be  permanently  worn ;  a 
rubber  tube  to  which  a  short  funnel  is  attached  is  then  connected 
and  the  food  poured  in  through  this.  Many  patients  chew  a  por- 
tion of  their  food  and  transfer  it  to  a  vessel  which  is  connected  with 
the  canula  by  means  of  the  rubber  tube." 

However,  it  is  to  be  regretted  that  the  diverticulum  or  the  dila- 
tation of  the  oesophagus  is  not  removed  by  gastrostomy.  The  intro- 
duction of  food  into  the  body  is  naturally  no  longer  prevented,  but 
above  the  stricture  there  remains  a  breeding-place  for  all  kinds  of 
putrefactive  germs.  The  patients  are  constantly  swallowing  saliva  ; 
although  after  the  formation  of  the  fistula  they  complain  very  little 
or  not  at  all  about  hunger,  they  are  frequently  troubled  with  severe 


104  DISEASES  OP  THE  STOMACH. 

thirst.  We  may  permit  tliem  to  swallow  small  pieces  of  ice  and  even 
to  drink  some  wine.  Later  the  dilated  gullet  becomes  filled  with  fluid 
contents  which  at  once  putrefy,  a  strong  fetid  odor  emanates  from 
the  mouth,  and  either  spontaneously  or  through  the  stomach-tube 
the  patients  force  up  a  fluid  with  the  odor  of  decaying  meat,  which 
on  microscopic  examination  proves  to  be  almost  a  pure  culture  of 
putrefaction  cocci.  Under  such  circumstances  we  must  wash  out 
the  sacculation  as  we  do  a  stomach,  and  for  this  purpose  we  may  use 
disinfecting  fluids  (salicylic  acid,  thymol,  resorcin,  borax,  etc.),  or 
we  may  introduce  salicylic  acid  or  boric  acid  in  substance.  I  have 
also  given  strong  cognac  in  teaspoonful  doses  in  order  to  get  the  dis- 
infecting action  of  the  alcohol. 

Finally,  a  word  about  feeding. 

At  an  early  period  the  patients'  own  experience  teaches  them  to 
take  gruels  and  fluid  nourishment  instead  of  solid  food.  Since  the 
functions  of  the  stomach  themselves  have  not  suffered,  as  long  as  the 
lesion  is  not  a  cancerous  growth — about  which  more  hereafter — we 
must  only  consider  the  digestibility  of  the  food  in  so  far  that  we  do 
not  give  indigestible  articles  of  diet  to  persons  who  are  more  or  less 
debilitated,  but  that  we  must  try  to  give  as  much  nourishment  as 
possible  in  the  most  compact  form.  Besides  pure  milk,  the  paps 
and  broths  known  in  every  kitchen,  raw  and  soft-boiled  eggs,  thick 
gruels  of  wheat,  oatmeal,  and  barley  flour,  we  may  also  use  the  so- 
called  leguminous  flours*  (containing  varying  quantities  of  nitro- 
gen) which  are  now  sold  in  various  forms,  as  well  as  beef  peptone 
and  peptone  chocolate  (see  p.  348).  We  can  also  make  a  palatable 
meat  broth  of  an  almost  sirupy  consistency  by  taking  raw  beef  which 
has  been  chopped  up  very  fine  and  stirring  it  with  an  egg  and  adding 
some  pepper  and  salt.  Kefir  is  readily  taken  by  some  for  a  long  time 
on  account  of  its  acid  taste,  while  it  soon  becomes  repugnant  to 
others.  Moreover,  in  this  respect  it  presents  no  exceptions  to  the 
rest  of  the  artificial  food  preparations,  all  of  which  have  the  same 
disadvantage  of  always  sooner  or  later  becoming  unpleasant  or  even 
disgusting.    ISTature  does  not  permit  herself  to  be  mocked  at ;  and  if, 


*  [VideJl.Schlesinger.  Aerztliches Hulfsbiichlein.   Frankfurt,  1891,  2te  Auflage, 
S.  15.— Tr.] 


RECTAL  ALIMENTATION.  105 

for  instance,  slie  provides  albuminoids,  in  various  forms  in  the  com- 
mon foods  and  not  pure  peptones,  we  can  not  substitute  the  latter 
for  the  former  without  being  punished  in  regard  to  the  taste  and  its 
results.  However  much  the  praises  of  the  excellent  flavor  of  these 
preparations  may  be  sung,  they  all  have  the  fault  just  spoken  of,  and 
a  substitute  for  ordinary  food  with  a  good  taste  that  is  always  pleas- 
ant and  agreeable  is  still  to  be  found. 

The  amylaceous  flours,  such  as  tapioca,  arrowroot,  and  sago,  can 
not  be  recommended — first,  because  they  are  very  poor  in  nitrogen, 
in  fact  in  nourishment  altogether,  and  secondly,  because  the  diastatic 
action  of  the  saliva  is  needed  for  their  conversion  ;  but  this  reaches 
the  stomach  in  a  smaller  amount  than  usual,  since  it  is  produced  in 
a  smaller  quantity  inasmuch  as  the  stimulus  for  a  more  marked  se- 
cretion of  saliva,  the  mastication  of  solid  food,  is  practically  entirely 
abolished. 

Yery  soon,  however,  there  arises  the  necessity  of  supplementing 
the  deficient  nourishment  by  the  mouth  by  means  of  the  administra- 
tion of  food  ]3er  rectum.  Although  rectal  alimentation  dates  back 
to  the  earliest  times  in  medicine,  yet  great  credit  is  due  to  Kuss- 
maul,  Leube,  Rosenthal,  and  others  for  having  placed  it  on  a  scien- 
tific basis.  The  necessary  confidence  in  this  method  of  feeding 
was  supplied  by  the  proof  that  we  could  maintain  the  nitrogen 
equilibrium  in  animals  by  rectal  injections  of  peptone  and  pej)tone- 
like  bodies  ;  but  it  Avas  an  error  to  suppose  that  we  must  use  pep- 
tonized albumen  for  this  purpose.  In  a  special  series  of  experi- 
ments *  I  proved  that  the  injection  of  common  emulsified  white  of 
Q%^  serves  the  same  purpose,  and  that  the  mucous  membrane  of  the 
lower  portion  of  the  intestine  manifestly  possesses  the  power  of  ab- 
sorbing not  only  peptones  but  unchanged  white  of  egg  as  well,  and 
to  render  it  useful  in  the  metabolism  of  the  body.  In  estimating 
the  values  of  peptones  in  rectal  feeding,  the  conditions  in  alimenta- 
tion by  the  intestine  and  by  the  stomach  have  been  falsely  placed  on 
the  same  basis,  although  they  differ  fundamentally,  since  in  the 
former  case  the  mucous  membrane  is  healthy  and  in  the  latter  it  is 


*  C.  A.  Ewald.     Ceber  die  Ernahrung  mit  Pepton-  und  Eierklystieren.     Zeit- 
sclir.  f.  klin.  Med.,  Bd.  xii,  Heft  5  u.  6. 


106  DISEASES  OP   THE  STOMACH. 

diseased  and  its  functions  more  or  less  impaired.  Hence  in  the  one 
case  the  indication  is  to  diminish  as  much  as  possible  the  work  of  the 
org'an  so  far  as  it  concerns  the  chemical  changes  of  the  food.  In 
the  other,  however — i.  e.,  in  rectal  alimentation — there  is  a  healthy 
mucous  membrane  capable  of  performing  its  functions,  and  it  is  not 
necessary  to  do  a  portion  of  its  work  outside  of  the  body.  We  will 
never  be  placed  in  the  230sition  to  employ  nutrient  enemata  when 
the  intestinal  mucous  membrane  is  unhealthy,  because  in  the  vast 
majority  of  such  cases  the  stomach  is  capable  of  performing  its 
duties.  However,  should  both  stomach  and  rectum  be  diseased  in 
the  same  patient — and  this  is  one  of  the  greatest  rarities — and  should 
indeed  the  question  of  artificial  nutrition  arise,  feeding  by  the  mouth 
would  always  offer  the  better  chances. 

I  therefore  believe  that  peptones  may  be  dispensed  with  in  nutri- 
tive enemata.  In  no  case  ought  it  be  necessary  to  use  the  compli- 
cated procedure  recommended  some  time  ago  by  Leube.  This  con- 
sisted of  a  mixture  of  chopped  meat,  fat,  and  fresh  pig's  pancreas, 
which  is  injected  into  the  intestine,  where  it  is  gradually  peptonized. 
For  this  purpose  we  may  now  use  the  j^eptone  preparations  offered 
for  sale,  although  most  of  them  are  only  gelatin-peptones ;  more- 
over, they  only  contain  a  small  percentage  of  true  peptones,  being 
rather  the  earlier  products  in  the  formation  of  the  same — i.  e.,  syn- 
tonin  and  propeptone.  E^evertheless  they  represent  stages  in  the 
transformation  of  native  albumen.  As  a  matter  of  convenience 
suppositories  have  been  made  of  these  peptone  preparations  ;  but, 
as  has  been  said,  the  peptones  are  entirely  suj^erfluous.  I  order  the 
nutrient  enemata  to  be  prepared  as  follo\vs  :  A  pinch  of  the  best 
flour  is  cooked  with  half  a  cupful  of  a  20-per-cent  solution  of  glucose 
and  a  wineglassful  of  claret  added.  Two  or  three  eggs  are  beaten 
up  smooth  with  a  tablespoonful  of  water  and  slowly  stirred  in  with 
this  after  it  has  cooled  sufficiently  to  prevent  the  coagulation  of  the 
albumen.  The  entire  quantity  should  not  measure  more  than  ^  litre 
[|-  pint].  In  hospital  practice  or  with  the  poor,  three  to  five  eggs, 
with  about  150  c.  c.  [f  ^  v]  of  a  15  to  20  per  cent  solution  of  glucose, 
may  either  be  injected  or  allowed  to  flow  in.  If  necessary  to  make 
the  mass  thicker,  we  can  add  starch  solution  or  mucilage  ;  or  a  few 
drops  of  tincture  of  opium  to  lessen  any  possible  irritation.     Ac- 


KECTAL  ALIMENTATION.  107 

cording  to  Huber,*  who  repeated  and  confirmed  my  experiments, 
the  efficacy  of  the  egg-enema  may  be  increased  by  the  addition  of 
some  common  salt,  in  the  proportion  of  about  one  gramme  [gr.  xv] 
to  eacli  egg.  A  cleansing  enema  of  250  c.  c.  [f  §  viij]  of  lukewarm 
water  or  of  salt  solution  must  always  precede  the  nutrient  enema, 
and  we  must  wait  till  the  passages — often  frequent — are  over ;  other- 
wise it  may  happen  that  the  nutrient  enema  will  be  immediately 
ejected.  Such  injections  may  either  be  given  two  or  three  times  a 
day  or  the  quantity  divided  into  smaller  enemata.  During  such  a 
course  the  faeces  readily  assume  a  ribbon-like  form  and  a  light 
yellow  color.  This  must  be  borne  in  mind  so  that  no  errors  may 
arise  in  a  given  case. 

Such  enemata  may  be  given  for  a  long  time  without  the  intestine 
reacting  and  causing  their  rapid  expulsion.  "We  must  only  use  the 
precaution  of  allowing  the  fluid  to  flow  in  very  slowly  through  a 
soft  tube  introduced  as  high  as  possible  into  the  bowel,  the  best 
being  a  large  ISTelaton  catheter  or  an  oesophageal  tube  with  an  eye 
at  the  lower  end  and  numerous  lateral  openings.  The  irrigator  is 
held  about  two  feet  above  the  anal  orifice  of  the  patient  or  the 
piston  of  the  syringe  or  the  rubber  bulb  is  worked  gradually.  For 
some  time  after,  the  patient  remains  either  in  the  dorsal  or  left  lateral 
position.  In  case  of  marked  irritability  of  the  intestines  a  few  drops 
of  tincture  of  opium  may  be  added  to  the  enema  at  first ;  but  this 
soon  becomes  superfluous  and  is  rarely  necessary  for  any  length  of 
time.  I  have  never  seen  more  than  a  transient  benefit  derived  from 
the  rubber  tampons  (similar  to  the  colpeurynter)  devised  for  keeping 
back  the  injected  fluid.  They  are  pushed  into  the  bowel  beyond 
the  sphincter,  and  are  then  dilated  with  air  or  water.  They  can  not 
be  passed  beyond  the  third  sphincter,  and  after  they  have  resisted 
the  intestinal  peristalsis  several  times  they  lose  their  efficacy ;  also, 
owing  to  the  irritation  which  they  produce  on  the  mucous  mem- 
brane, they  render  the  intestine  still  more  sensitive  and  intolerant  to 
the  injections  than  would  be  the  case  without  them. 

Finally,  the  nourishment  after  the  production  of  a  gastric  fistula 
is  to  be  considered.     The  kind  and  quantity  of  food  which  will  be 

*  A.  Huber.     Deutsch.  Archiv  fiir  klin.  Med.,  Bd.  xlvii. 


108  DISEASES   OF  THE   STOMACH. 

l)orne  under  such  circumstances  will  depend  primarily  upon  the 
nature  of  the  original  disease.  The  celebrated  Canadian,  Alexis  St. 
Martin,  seems  to  have  consumed  very  nourishing  food  without  any 
detriment.  I  have  myself  seen  the  boy  with  the  cicatricial  oesopha- 
geal stricture  who  was  operated  on  by  Trendelenburg  enjoy  bread 
and  butter,  together  with  meat,  potatoes,  and  vegetables,  which  he 
introduced  into  the  fistula.*  The  patient  operated  on  by  Yerneuil 
also  had  an  ample  bill  of  fare  from  which  to  choose.f  However, 
these  are  all  cases  of  a  non-cancerous  nature  with  relatively  good 
general  condition  in  which,  no  doubt,  at  first  a  nutrient  solution  as 
unirritating  and  simple  as  possible  was  poured  into  the  fistula  and  a 
mixed  diet  given  only  later  on.  The  digestive  functions  of  the  stom- 
ach in  such  cases  seem  to  have  suffered  very  little,  although  no  exact 
investigations  have  yet  been  made  on  the  subject.  In  cases  where 
gastrostomy  is  performed  for  carcinoma  of  the  cardia  (whether  situ- 
ated on  its  oesophageal  or  gastric  side),  what  are  the  changes  in  the 
secretion  of  the  gastric  juice  and  in  the  digestive  functions  of  the 
stomach  ?  It  is  self-evident  that  the  feeding  must  vary  considerably 
according  to  the  answer  to  this  question  ;  but  it  is  also  clear  that, 
partly  at  least,  this  will  coincide  with  the  usual  changes  in  the  di- 
gestive functions  in  gastric  cancer.  I  shall  discuss  these  relations  in 
their  proper  connection  in  Lecture  Y ;  but  I  will  anticipate  and  say 
that  in  three  cases  which  were  operated  upon  I  have  never  found 
any  secretion  of  hydrochloric  acid  or  of  pepsin.  In  two  of  these, 
who  died  a  short  time  after  the  operation,  this  might  be  ascribed  to 
the  weakness  of  the  patients ;  but  the  third,  the  previously  men- 
tioned case  of  carcinomatous  stricture  of  the  oesophagus,  with  numer- 
ous metastases,  is  more  important.  Here  the  chyme  flowing  from 
the  fistula  was  repeatedly  examined,  the  last  time  four  months  sub- 
sequent to  the  operation,  after  the  patient  had  introduced  gruel,  or 
gruel  with  egg  and  zwieback,  one,  one  and  a  half,  and  two  hours  pre- 
viously. The  mass  which  flowed  out  was  invariably  only  slightly 
changed,  containing  a  little  mucus,  of  neutral  reaction,  without  pep- 


*  He  chewed  the  food,  and  then  pressed  it  from  his  mouth  into  his  stomach 
through  a  large  rubber  tube. 

f  Cited  by  Ch.  Richet.  Du  sue  gastrique  chez  I'homme  et  les  animaux.  Paris, 
1878,  p.  88. 


FEEDING  AFTER  aASTROSTOMY.  109 

tone,  and  its  filtrate  liad  no  digestive  action  eitliei-  on  tlie  addition 
of  hydrochloric  acid  or  of  pepsin.  The  secretion  of  the  glands,  there- 
fore, had  ceased  completely  and  permanently.  I  wish  to  state  that  in 
the  other  cases  even  before  the  operation,  while  it  M^as  still  possible 
to  introduce  a  sound  into  the  stomach,  I  found  the  chyme  to  be  like- 
wise free  from  the  peptic  secretion.  The  same  result — i.  e.,  the  ab- 
sence of  hydrochloric  acid— was  found  by  IsTeschaieff  *  in  105  exami- 
nations on  four  patients  with  carcinomatous  stricture  of  the  oesopha- 
gus. Riegel  f  found  a  diminished  or  normal  secretion — therefore  with- 
out characteristic  change — in  two  cases,  but  the  site  of  the  carcinoma 
is  not  accurately  given  and  the  stricture  was  undoubtedly  still  patent. 
Under  the  circumstances  wdiich  I  have  described  it  is  evident 
that  we  must  refrain  as  far  as  possible  from  giving  food  which  in 
any  way  demands  more  of  the  stomach  than  that  which  can  be  ab- 
sorbed and  passed  on  into  the  intestine  as  quickly  as  possible.  This, 
therefore,  is  where  the  various  peptone  preparations  are  indicated. 
They  must  be  supplemented  with  carbohydrates  and  fats.  In  order 
to  compensate  for  the  absence  of  the  diastatic  action  of  the  saliva 
we  give  its  product,  glucose,  or  we  allow  the  patients  to  mix  the 
food  with  saliva  by  mastication  and  then  to  transfer  it  by  means  of 
a  tube  directly  from  the  mouth  to  the  stomach.  In  such  cases  the 
nutrition  depends  entirely  on  the  preservation  of  the  absorptive  and 
motor  functions  of  the  stomach,  and  therefore  the  "  diet "  of  such 
patients  could  be  made  typically  simple  and  restricted  to  simply  a 
solution  of  peptone  and  glucose,  together  with  some  fat,  were  it  not 
that  we  must  take  account  of  their  desire  to  masticate  and  taste  the 
food  and  thus  satisfy  the  sensation  of  hunger  as  well  as  their  ges- 
thetic  sensations.  Even  our  patient  chewed  meat  and  zwieback, 
and  forced  the  masticated  morsels  into  the  fistula  through  a  rubber 
tube  in  the  firm  belief  of  thus  "  offering  something  to  the  stom- 
ach." Luckily,  it  did  not  accept  this,  but,  as  it  seems,  promptly 
transferred  these  morsels  into  the  intestines. 


*  Lancet,  June  4,  1887.  It  is  not  stated  where  the  original  paper  is  to  be  found, 
and  it  remains  doubtful  whether  Neschaieff  examined  the  contents  of  the  oesopha- 
gus— or  diverticulum — or  of  the  stomach. 

f  F.  Riegel.  Beitrage  zur  Diagnostik  der  Magenkrankheiten.  Zeitschr.  f.  klin. 
Med.,  Bd.  xii,  S.  434. 


LECTUEE   lY. 

STENOSES     AND    STEICTUEES    OF    THE     PYLORUS. MEGASTEIA     AND    GAS- 

TRECTASIA, DILATATION    OF    THE    STOMACH. 

Gentlemen  :  To-day  I  shall  show  you  a  series  of  plaster  casts  of 
stomachs  which  were  made  by  filling  the  viscus  with  liquefied  tal- 
low after  it  had  been  removed  from  the  body  and  tying  at  both 
cardia  and  pylorus.  Matrices  were  then  taken  from  the  casts  thus 
formed,  and  the  plaster  models  made  from  these. 


Fig.  11.  Fig.  12.  Fig.  13. 

[Fig.  11. — Cast  of  cylindriform  stomach  in  vertical  position.     Female.     Ziemssen. 
Fig.  12. — Cast  of  normal  stomach.     Female.     Ziemssen. 
Fig.  1.3. — Cast  of  dilated  stomach  in  vertical  position.     Female.     Ziemssen. — Te.] 

At  the  request  of  Prof,  von  Ziemssen  a  Munich  artist  has  made 
papier-mache  models  of  the  pathological  forms  only,  and  of  these 
I  am  enal:)led  to  show  you  two  specimens  of  enormous  gastric  dila- 
tation [.see  Figs.  11,  12,  13,  and  14].*     You  can  most  thoroughly 

*  [Figs.  11,  12, 13,  and  14  are  from  photographs  of  some  of  these  plaster-of- Paris 
casts.  They  were  all  taken  at  the  same  distance  from  the  camera,  and  were  placed 
in  the  position  which  they  occupied  in  the  body.  The  differences  in  form,  position, 
and  size  have  thus  been  preserved.  Concerning  the  vertical  position  of  the  stom- 
ach, see  p.  117.-^Tr.] 


VARIATIONS  IX  SIZE   OF  STOMACH.  m 

convince  yourselves  of  the  -well-known  fact  *  of  the  variations  in 
form  and  size  of  the  stomach  by  examining  these  remaining  eight 
or  ten  specimens,  all  of  which  were 
obtained  from  persons  of  about 
the  same  size,  who  had  never  dur- 
ing life  complained  of  any  dis- 
turbance of  digestion.  Besides  the 
simple  purse-shaped,  we  find  stom- 
achs which  are  elongated,  almost 
like  a  sausage,  and  others  in  which 
— be  it  remembered,  "without  the 
action  of  cicatricial  contraction — 
a  marked  exaggeration  of  the  so- 

'-^  _      _  [Fig.  14. — Cast  of  a  markedly  dilated  stom- 

ealled     antrum    pylori    (i.     e.,    the  ach  tending  to  assume  vertical  position. 

1 .  J.        1    •         •      £         i.     £  iX.  Female.     Ziemssen. — Te.1 

lower  quarter  lying  m  front  oi  the  -' 

pylorus)  has  almost  caused  the  viscus  to  assume  tlie  shape  of  an 
hour-glass.  Just  as  the  form,  so  varies  the  capacity  of  the  stomach, 
which  in  these  preparations  was  always  determined  by  filling  them 
with  water.  The  largest  stomach  held  1,680  c.  c.  [56  fl.  oz.],  the 
smallest  only  250  c.  c.  [S  fi.  oz.]  ;  between  these  limits  we  find  all 
possible  variations. 

From  this  demonstration  you  can  infer  that  there  is  no  absolute 
standard  for  the  size  of  the  normal  stomach,  at  least  within  the 
given  limits,  and  that  its  capacity  by  no  means  bears  a  fixed  relation 
to  the  size  of  the  body.  "We  may  find  a  very  large  stomach  in  a 
comparatively  small  individual,  and  vice  versa.  We  can  only  speak 
of  an  absolute  dilatation  of  the  stomach  when  it  exceeds  the  given 
capacity  in  round  numbers  of  1,600  to  1,700  c.  c.  [53  to  5Y  fl.  oz.]. 
But  the  stomach  may  be  actually  much  smaller  and  yet  be  relatively 
dilated  for  the  individual. 

Finally,  as  Kussmaul  and  Rosenbach+  have  already  shown,  there 
exist  very  large  stomachs  which  exert  no   disturbing  influence  on 

*  For  example,  Von  den  Velden  has  laid  great  stress  upon  this  in  his  paper, 
Ueber  Vorkommen  und  Mangel  der  freien  Salzsaure  im  Magensaft  bei  Gastreetasie. 
Deutsch.  Archiv  f.  klin.  Med..  Bd.  23,  S.  369.  His  results  are  based  upon  the  clini- 
cal lectures  of  Prof.  Kussmaul. 

f  O.  Rosenbaeh.  Der  Mechanismus  und  die  Diagnose  der  Mageninsufficienz. 
Volkmann's  Sammlung  klinisehe  Vortrage,  Xo.  153,  p.  8. 


112  DISEASES  OP  THE  STOMACH. 

digestion,  so  that  tliey  are  discovered  accidentally  wliile  making 
some  other  examination.  I  therefore  distinguish  l^etween  the  large 
stomachy  inegastria,  and  the  enlargement  of  the  stomachy  gastric 
dilatation  or  gastrectasia,  which  in  turn  is  to  be  divided  into  an 
acute  or  subacute  and  a  chronic  form.  Megastria  may  lead  to  dila- 
tation, but  is  not  a  pathological  occurrence.  Thus  it  amounts  to 
an  anatomical  condition,  while  the  nature  of  dilatation  is  that  of 
a  functional  disturbance,  combined  with  a  progressive  anatomical 
process. 

Germain  See  *  also  distinguishes  between  simple  dilatation,  which 
may  exist  for  a  long  time,  or  even  permanently,  without  creating 
any  disturbance  and  dilatation  with  dyspepsia — i.  e.,  that  condition 
which  we  commonly  regard  as  gastric  dilatation,  by  which  we  do  not 
mean  simply  a  large  stomach,  but  that  there  is  at  the  same  time  a 
morbid  disturbance  of  its  function.  I  understand  dilatation  of  the 
stomach,  or  gastrectasia  to  be  that  condition  of  the  viscus  which  is 
accompanied  by  the  clinical  symptoms  of  disturbed  gastric  function 
due  to  the  enlargement  of  the  organ,  and  megastria  to  be  the  ac- 
quired or  congenital  large  stomach  the  abnormal  anatomical  state  of 
which  is  functionally  compensated.  The  "  large  stomach "  may 
become  catarrhal,  and  its  owner  dyspeptic ;  but,  clinically  speaking, 
such  a  patient  has  no  gastrectasia,  although  more  disposed  thereto 
than  others.  Megastria  and  gastrectasia  have  frequently  been 
confounded  with  each  other.  An  entirely  different  condition,  if  I 
maj^  anticipate,  is  gastric  insitfficiency,  which  indeed  may  and  fre- 
quently does  lead  to  the  symptoms  of  gastrectasia,  yet  does  not 
have  the  anatomical  basis  of  the  dilated  stomach,  but  is  a  functional 
disturbance  occurring  in  the  most  varied  conditions  of  size  of  the 
organ. 

We  possess  the  following  diagnostic  aids  for  the  recognition  of 
the  large  or  dilated  stomach: 

1.  Inspection. — With  relaxed  and  thin  abdominal  walls  we  fre- 
quently see  the  left  hypochondriac  region  and  a  larger  or  smaller 
portion  of  the  right,  according  to  the  extent  to  which  the  stomach 
is  filled  with  air  or  ingesta,  bulge  out  like  a  hemisphere  or  balloon, 

*  Germain  See.     Du  regime  alimentaire.     Paris,  1877,  p.  280. 


PHYSICAL  SIGNS  OF  GASTRECTASIS.  II3 

beginning  just  below  the  free  margin  of  the  ribs.  The  lower  border 
of  this  swelling  crosses  the  mid-line  on  a  level  with  the  umbilicus, 
or  below  this,  between  it  and  the  symphysis.  At  times  there  is  only 
a  lower  projection  present,  with  a  trough-like  depression  between  it 
and  the  free  border  of  the  ribs,  which  is  caused,  as  a  rule,  by  the 
long  axis  of  the  stomach  assuming  a  more  or  less  vertical  position  ; 
occasionally,  however,  it  may  be  produced  by  the  region  of  the  lesser 
curvature  becoming  collapsed,  while  the  fundal  zone  is  inflated 
or  filled  with  ingesta.  In  the  former  case  the  lesser  curvature  runs 
parallel  to  the  spinal  column  in  the  middle  line,  or  even  to  the  left 
of  it,  and  in  highly  marked  degrees  of  this  condition  it  only  passes 
to  the  right  on  a  level  with  the  umbilicus,  so  that  even  the  pancreas 
may  be  felt  between  the  margin  of  the  liver  and  the  stomach,  and 
may  be  mistaken  for  a  gastric  tumor  [see  Fig.  15].  Peristaltic 
waves  may  travel  over  the  stomach  from  left  to  right,  either  in  con- 
stant succession  or  as  the  result  of  external  mechanical  irritation  ; 
antiperistaltic  motions  may  also  be  observed  (Bamberger,*  Cahn,f 
Glax :{:).  If  we  inject  air  into  the  stomach,  these  conditions  become 
still  more  marked,  and  the  gradual  appearance  of  the  viscus  as  it  be- 
comes distended  produces  as  a  rule  a  very  characteristic  picture.  In 
advanced  dilatation  the  body  is  usually,  though  not  always,  emaci- 
ated, the  abdominal  walls  are  relaxed  and  slightly  sunken,  and  the 
false  ribs  on  the  left  side  are  raised  like  a  wing.  The  skin  is  dry, 
pale,  and  somewhat  tawny. 

2.  Percussion. — Should  any  suspicion  of  dilatation  exist,  it  is 
best  before  percussing  to  first  distend  the  stomach  with  air.  (Lect- 
ure II,  page  59.)  Only  lately  I  have  had  occasion  to  experience 
the  importance  of  using  the  double-bulb  apparatus  instead  of  setting 
carbonic-acid  gas  free  in  the  stomach.  A  colleague  failed  to  recog- 
nize a  marked  dilatation,  which  extended  to  midway  between  the 
umbilicus  and  the  symphysis,  in  spite  of  his  having  given  a  Seidlitz 
powder  to  the  patient,  because  the  quantity  of  gas  evolved  was  actu- 

*  L.  Bamberger.  Krankheiten  des  chylopoetisehen  Systems.  Erlangen,  1855, 
S.  325. 

f  A.  Cahn.  Antiperistaltische  Magenbewegungen.  Deutsch  Archiv.  f.  klin. 
Med.,  Bd.  35,  S.  402. 

X  A.  Glax.  Ueber  peristaltische  und  antiperistaltische  Unruhe  des  Magens. 
Pester  med.  ehirurg.  Presse,  1884. 


X14  DISEASES  OF  THE  STOMACH. 

ally  insufficient  for  the  capacity  of  the  stomach.  The  percussion 
note  over  the  inflated  stomach  is  always  tympanitic  and  more  or  less 
high  according  to  the  contents  and  the  tension  of  its  walls.  Should 
the  transverse  colon  be  markedly  distended  and  the  curvature  of  the 
stomach  lie  immediately  next  it,  it  may  at  times  emit  the  same  note, 
and  thus  render  it  an  impossibility  to  define  the  boundary  between 
the  two  organs  by  means  of  percussion.  In  such  a  case  we  must 
either  fill  the  stomach  with  fiuid,  and  then  percuss  in  order  to  con- 
trast its  dullness  with  the  tympanites  of  the  colon ;  or  we  must  force 
more  air  into  the  latter  from  the  rectum,  thereby  producing  either 
a  change  in  position  or  a  higher  tympanitic  note.  Here  it  is 
w'ell  to  remember  that  the  more  delicate  differences  in  sound  fre- 
quently become  more  distinct  by  the  use  of  auscultatory  percussion 
when  the  ordinary  method  of  percussion  with  the  pleximeter  leaves 
us  in  the  lurch,  and  that  therefore  this  method  can  also  be  utilized 
in  doubtful  cases.  Ferber  *  has  called  attention  to  the  fact  that  the 
circular,  tympanitic  "  stomach-lung  region  "  {Magen-Ltmgenrmmi) 
formed  by  the  stomach  under  the  lower  lobe  of  the  left  lung 
gradually  disappears  behind  the  axillary  line  if  the  organ  be  normal, 
while  if  it  be  dilated  it  may  be  traced  to  the  vertebral  column.  Yet 
it  is  evident,  a  priori,  that  this  must  depend  essentially  upon  the 
quantity  of  gas  and  ingesta  in  the  stomach  and  intestines.  These 
force  the  organ  more  or  less  into  the  hollow  of  the  diaphragm  in 
such  a  manner  that  the  resulting  tympanitic  zone  in  favorable  cases 
may  and  indeed  does  extend  as  far  as  the  vertebral  column  even 
with  a  stomach  of  normal  size.  Judging  by  my  experience  thus  far, 
the  following  method,  recommended  by  Dehio  f  for  determining  the 
boundaries  of  the  stomach  in  normal  and  pathological  conditions 
appears  to  be  far  more  valuable.  On  an  empty  stomach  the  patient 
drinks  a  litre  [quart]  of  Avater  interruptedly  in  four  portions  of  i 
litre  [  §  viij]  each.  If,  now^,  after  every  \  litre  we  percuss  out  the 
resultant  lower  crescentic  limit  of  dullness  against  the  tympanitic 
transverse  colon,  we  find  in  a  healthy  person,  while  erect,  that  the 

*  Ferber.  Ein  Beitrag  zur  Magenpercussion,  etc.  Deutsche  Zeitschr.  f.  prakt. 
Med.,  1876,  No.  42. 

f  Dehio.  Zur  physikalischen  Diagnostik  der  mechanisehen  Insufficienz  des  Ma- 
gens.    Verhandl.  des  vii.  Congresses  f.  innere  Medicin,  1888. 


PHYSICAL  SIGNS  OF  GASTRECTASIS.  115 

stomach  moves  downward  according  to  the  greater  amount  of  fluid 
it  contains,  but  that  it  never  extends  beyond  the  umbilicus  as  a  rule, 
coming  onlv  to  within  a  few  centimetres  [an  inch]  of  the  same.  In 
the  recumbent  posture  we  get  a  tympanitic  note  due  to  the  air  swal- 
lowed with  the  water,  and  this  prompt  change  of  the  percussion  note 
is  a  strong  proof  that  we  are  dealing  with  the  stomach  and  not  per- 
chance with  the  intestine. 

At  the  same  time  this  procedure  allows  us  to  recognize  the  con- 
ditions, to  be  discussed  presently,  of  motor  insufiiciency  or  atony 
of  the  stomach— i.  e.,  its  temporary  dilatation  and  its  persistent  ecta- 
sis — which  so  often  is  the  immediate  result  of  the  former ;  for  it  is 
evident  that  the  more  relaxed  the  gastric  walls  are,  the  sooner  will 
the  lower  boundary  of  the  stomach  reach  its  most  dependent  posi- 
tion even  after  the  introduction  of  small  quantities  of  fluid,  or  in 
cases  of  marked  dilatation  it  will  be  found  in  an  abnormally  low 
position  at  the  very  commencement.  The  conditions  which  must 
exist  to  enable  us  to  use  this  method  of  exploration  are,  of  course, 
that  the  intestines  and  especially  the  transverse  colon  must  contain 
air ;  that  there  is  no  abnormal  configuration  of  the  stomach ;  and, 
finally,  that  the  abdominal  walls  are  not  so  thick  as  to  entirely  pre- 
vent the  transmission  of  the  more  delicate  differences  in  sound. 

Finally,  I  quote  the  results  of  Pacanowski,*  which  he  obtained 
by  the  careful  examination  of  81  cases — 55  males  and  26  females — 
in  order  to  give  you  some  criterion  whereon  to  base  your  ideas  of 
the  normal  size  of  the  stomach,  or,  better,  of  that  part  which  is  pro- 
jected upon  the  abdominal  walls  when  the  organ  is  filled  with  air 
nnder  medium  tension.  Agreeing  fairly  closely  with  earlier  observ- 
ers ("Wagner,  for  instance),  he  found  that  in  the  left  parasternal  line 
the  lowest  boundary  of  the  stomach  in  men  lies  most  often  3  to  5 
centimetres  [1^  to  2  inches]  above  the  umbilicus,  and  4  to  Y  centi- 
metres [If  to  2|-  inches]  above  in  women.  The  distance  between  the 
highest  and  lowest  points  of  the  zone  of  stomach  tympanites  was  11 
to  14  centimetres  [4|-  to  5|-  inches]  in  men  and  about  10  centimetres 
[1  inches]  in  women.     The  width  of  this  zone  amounted  to  21  centi- 


*  H.  Pacanowski.     Beitrae:  zur  percutorischen  Bestimraung  der  Magengrenzen. 
Deutsch.  Arch.  f.  klin.  Med.,  Bd.  xl,  S.  343. 


116  DISEASES  OP  THE  STOMACH. 

metres  [Sf  inches]  and  18  centimetres  [Y-g-  inches],  respectively. 
Nevertheless,  in  accord  w^ith  our  experience,  spoken  of  at  the  com- 
mencement of  this  lecture,  concerning  the  varying  conditions  of  size 
of  the  normal  stomach,  Pacanowski  found  fairly  marked  deviations 
from  these  averages.  Thus,  for  instance,  he  gives  9  centimetres  [3f 
inches]  and  20  centimetres  [8  inches]  for  the  vertical  measurement, 
and  16  centimetres  [6f  inches]  and  25  centimetres  [10  inches]  for 
the  width,  and  that  without  being  able  to  infer  that  pathological 
conditions  existed.  From  this,  therefore,  it  is  also  manifest  that  the 
absolute  conditions  of  size,  as  far  as  we  are  able  to  arrive  at  them 
by  the  physical  methods  of  examination,  are  to  be  regarded  as  of 
only  conditional  value  in  the  diagnosis  of  dilatation  of  the  stomach 
— i.  e.,  only  in  cases  of  excessive  ectasis — for  it  may  easily  happen 
that  an  originally  small  stomach  may  acquire  a  pathological  dilata- 
tion with  its  resultant  clinical  features,  and  that  nevertheless  its  ab- 
solute measurement  may  remain  within  those  bounds  which  are  to 
be  regarded  as  normal. 

3.  Palpation. — I  will  simply  mention  the  palpation  of  tumors 
of  the  pylorus  in  this  place,  reserving  its  explicit  discussion  for  later. 
Leube  has  recommended  "palpation  of  the  tip  of  the  sound"  in 
order  to  recognize  dilatation  of  the  stomach.  A  stiff  sound  is  intro- 
duced into  the  stomach  until  it  meets  with  resistance  as  far  as  this 
is  feasible  without  the  employment  of  undue  force.  If,  now,  the 
point  of  the  sound  can  be  palpated  below  the  level  of  the  umbilicus, 
dilatation  of  the  stomach  is  proved  to  exist.  This  method  has  been 
objected  to  on  the  ground  that  it  might  be  dangerous,  and  that  it  is 
frequently  impossible  to  palpate  the  tip  of  the  sound.  Leube  has 
rejected  both  objections,  and,  as  far  as  the  former  is  concerned,  I 
fully  agree  with  him.  An  unusual  degree  of  roughness  would  be 
needed  to  perforate  the  gastric  wall ;  but  feeling  the  point  of  the 
sound  through  the  abdominal  walls  is  an  entirely  different  matter 
This  can  very  easily  be  done  if  we  are  dealing  with  an  advanced 
case  of  dilatation  of  the  stomach  in  which  the  abdominal  walls  are 
relaxed  and  sunken ;  but  in  such  cases  we  can  also  arrive  at  a  diag- 
nosis by  means  of  the  other  methods  of  examination.  However,  if 
the  case  be  that  of  a  comparatively  well-nourished  person,  it  is  most 
frequently  utterly  impossible  to  feel  the  sound  distinctly,  even  if  we 


VERTICAL  POSITION   OF  STOMACH. 


117 


go  over  the  whole  abdomen  as  carefully  as  we  can,  palpating  one 
square  inch  after  another.  Further,  in  experimenting  on  the  dead 
body  it  has  repeatedly  happened  to  me  tliat  the  ti23  of  the  sound  has 
failed  to  reach  the  lowest  portion  of  the  stomach.  It  was  much 
more  apt  to  be  caught  at  some  point  higher  up  and  to  push  this 
before  it  a  little,  but  it  nevertheless  remained  far  above  the  most 
dependent  portion.  Further,  we  must  remember  that  in  men  tlie 
stomach  is  not  infrequently  in  a  vertical  position,  and  that  this  is  the 
case  much  oftener  in  women,  a  fact  already  known  to  F.  Meckel. 
This  may  be  congenital,  or  it  may  be  due  to  pressure,  traction,  etc. 
The  lesser  curvature,  then,  is  almost  perpendicular,  and  the  pyloric 
portion  of  the  fundus  may  extend  to  below  the  umbilicus.  This 
malposition  may  not  infrequently  be  seen  in  the  dead  body  unac- 
companied by  any  abnormal  increase  in  the  capacity  of  the  stomach 
[see  Figs.  11,  13,  14,  and  15].*  Thus  the  stomach  of  the  performer 
described  by  H.  Yirchow  in  the 
Berlin  Anthropological  Society,f 
who  was  able  to  swallow  a  sword 
70  centimetres  [28  inches]  long, 
may  have  been  in  a  similar  posi- 
tion. Also,  by  the  cardia  becom- 
ing depressed  to  the  right  with 
the  pylorus  fixed  so  that  cardia 
and  pylorus  lie  close  together,  we 
can  get  a  marked  depression  of 
the  greater  curvature  on  account 
of  the  sharp  bend  in  the  upper 
border. 

For   all    these   reasons,    there- 
fore, palpation  with  the  sound  will  only  give  us  uncertain  results, 
as  Albutt :{:  says,  "  I  believe  that  the  palpation  of  the  tip  of  the 


[Fig.  15. — Stomach  in  vertical  position,  hi 
situ.    I'eniale.     Ziemssen. — Tr.J 


*  [The  views  expressed  by  Lesshaft  (Lancet,  1883.  vol.  i.  p.  406)  on  the  vertical 
position  of  the  stomach  have  since  been  gradually  accepted  by  many  writers. 
Ziemssen  considers  its  occurrence  very  frequent,  especially  in  woraen ;  in  them  it 
is  usually  the  result  of  tight  lacing ;  the  lower  ribs  being  fixed  and  the  epigastrium 
compressed,  no  room  is  left  for  the  distended  stomach  except  by  swinging  on  a  ver- 
tical axis  whose  fixed  point  is  the  cardia.  The  result  is  well  shown  in  Fig.  15. — 
Tr.]  f  Meeting  of  July  17,  1886.  %  Loc.  cit. 


llg  DISEASES  OF  THE  STOMACH. 

sound  is  unnecessary  when  tlie  abdominal  walls  are  thin,  while  in 
stouter  persons  the  instrument  can  not  be  distinctly  felt." 

4.  Auscultation. — If  we  place  our  hands  flat  on  the  region  of 
the  stomach  and  give  the  abdominal  walls  a  series  of  rapid  consecu- 
tive shocks,  or  if  we  shake  the  body  m  toto,  we  can  hear,  either  at  a 
distance  or  with  the  stethoscope,  sounds  of  a  splashing  character 
with  a  faint  metallic  timbre,  the  so-called  succussion  or  splashing 
sounds,  the  Glapotement  of  the  French.  *  In  themselves  they  have 
no  pathognostic  significance.  They  may  arise  in  the  transverse 
colon  as  well  as  in  the  stomach,  and  are  frequently  heard  under  per- 
fectly normal  circumstances  immediately  after  the  ingestion  of  a 
large  quantity  of  fluid,  when  they  can  readily  be  produced  by  short 
and  energetic  contractions  of  the  abdominal  muscles.  They  only 
become  pathognostic  (1)  when  they  are  present  some  time  after  fluid 
has  been  taken,  and  (2)  when  they  are  positively  produced  in  the 
stomach.  At  times  the  latter  can  only  be  determined  by  completely 
emptying  (siphoning  out)  the  stomach.  If,  then,  the  succussion 
sounds  persist,  they  are  to  be  referred  to  the  intestines.  These  con- 
ditions are  frequently  disregarded,  and  a  diagnosis  of  dilatation  of 
the  stomach  is  rashly  made.  In  this  way  only  can  we  explain  the 
fact  that  certain  French  authors  (Bouchard  and  others)  find  dilata- 
tion of  the  stomach  not  only  in  every  dyspeptic,  but  that  Bouchard 
finds  it  present  in  about  30  per  cent  of  all  sick  people.  This  is  an 
exaggeration  which  is  not  shared  by  sober-minded  observers  like 
Germain  See  and  Dujardin-Beaumetz.  Pauli  was  the  first  after 
Penzoldt  f  to  call  attention  to  a  sound  in  the  stomach  like  escaping 
vapor,  similar  to  that  made  by  uncorking  a  bottle  of  Seltzer  water, 
and  in  fact  this  can  occasionally  be  recognized  on  auscultating  in 
the  region  of  the  stomach  when  marked  fermentative  processes  are 
present.  Of  a  different  kind  are  the  sounds  called  by  Kussmaul  % 
"  cooing  or  clapping  sounds  "  {Gurr-  oder  Klatschgerdusche\  which, 

*  Audhui.  Du  bruit  de  flot  on  de  clapotage  de  I'estomac  comme  signe  de  dila- 
tation de  I'estomac.  Gaz.  des  hopit.,  1883,  No.  47. — Girandeau.  De  la  dilatation 
de  restomac.  Arch,  general,  de  med.,  1885,  p.  342.  Duplay,  in  1833,  was  the  first 
to  direct  attention  to  this  in  France. 

f  Penzoldt.     Die  Magenerweiterung.     Erlangen,  1877. 

X  Kussmaul,  in  Volkmann's  Samml.  klin.  Vortrage,  No.  181,  published  June  16, 
1880. 


PHYSICAL  SIGNS  OF  GASTRECTASIS.  119 

as  I  have  mentioned  above,  may  be  produced  in  many  persons,  both 
with  and  without  dilatation  of  the  stomach,  by  the  active  contraction 
of  the  abdominal  muscles  or  by  rapidly  alternating  pressure  and  re- 
laxation on  the  passive  abdominal  wall.  Contrary  to  the  succussion 
sounds,  they  are  best  produced  in  the  erect  posture. 

At  times  we  can  hear,  even  at  a  distance,  the  heart-sounds  re- 
sounding with  a  metallic  character  from  the  stomach  filled  with  air. 
Striimpell  *  speaks  of  sounds  which  could  be  heard  at  quite  a  dis- 
tance and  which  were  isochronous  with  resj^iration  in  a  patient  with 
dilatation  of  the  stomach.  The  note  produced  in  Stdhchen-Plesshn- 
eter-Percussion  f  also  has  a  metallic  character,  and  in  favorable 
cases  can  even  be  used  to  define  the  limits  of  the  organ  against  the 
coils  of  intestine  (Leichtenstern). 

The  occurrence  of  the  deglutition-inurinurs  can  not  be  utilized 
in  the  diagnosis  of  dilatation.  I  have  never  been  able  to  observe 
any  characteristic  change  in  them,  although  I  have  examined  every 
accessible  case  for  this  purpose. 

Kosenbach  has  suggested  a  method  which  is  based  upon  auscul- 
tation of  air  blown  through  a  tube  which  is  introduced  into  the 
stomach.  If  we  pour  water  into  a  healthy  stomach,  introduce  a 
tube  below  its  surface,  and  blow  in  air,  we  will  then  on  auscultation 
hear  large,  moist,  metallic  rales,  which  disappear  when  the  tube  is 
slowly  withdrawn  as  soon  as  its  eye  is  above  the  level  of  the  fiuid. 
Therefore  the  surface  of  the  fluid  is  assumed  to  be  at  the  spot 
where  the  rales  cease  to  be  heard.  If,  after  having  thus  determined 
this  point,  we  pour  an  additional  quantity  of  water,  say  one  litre 
[quart],  into  a  healthy  stomach,  we  will  find  that  the  level  of  the 
fluid  has  become  appreciably  higher,  while  in  the  case  of  an  exist- 
ing dilatation  very  little  displacement  is  said  to  occur.  In  practice 
this  method  is  quite  difiicult  to  carry  out,  and  may  be  placed  on  a 
plane  with  Leube's  palpation  of  the  sound,  inasmuch  as  it  is  un- 
necessary for  the  recognition  of  large  dilatations,  while  in  less 
marked  conditions  it  fails  of  its  purpose. 

*  Berl.  klin,  Wochenschr,,  1879,  No.  30.  Aus  den  Sitzungsberichten  der  med. 
Gesellschaft  zu  Leipzig. 

f  [This  is  a  form  of  auscultatory  percussion  in  which  the  percussion  note  is 
elicited  by  striking  a  pleximeter  with  some  hard  object,  as  a  lead-pencil,  handle  of 
percussion-hammer,  etc. — Tk.] 


120  DISEASES   OP  THE  STOMACH. 

5,  Mensuration  of  the  Stomach. — The  position  of  the  greater 
curvature  may  be  estimated  by  the  distance  to  which  a  rigid  sound 
can  be  introduced  into  the  stomach  till  it  meets  with  resistance. 
According  to  Penzoldt,  this  distance,  reckoned  from  the  incisor 
teeth,  normally  amounts  to  60  centimetres  [24  inches],  and  never 
equals  the  length  of  the  vertebral  column  ;  in  three  cases  of  dilata- 
tion of  the  stomach  it  was  YO  centimetres  [28  inches],  so  that  the 
length  of  both  the  introduced  portion  of  the  sound  and  of  the  ver- 
tebral column  were  equal.  Disregarding  the  factors  already  men- 
tioned, namely,  that  we  can  never  be  certain  whether  the  tip  of  the 
sound  has  really  reached  the  lowermost  point  of  the  stomach,  or 
whether  there  may  not  be  a  vertical  position  of  the  organ,  it  is 
impossible  to  give  an  absolute  iigure  for  the  distance  to  which  the 
sound  may  be  introduced  normally,  in  view  of  the  variable  con- 
ditions of  size,  concerning  which  I  have  spoken. 

I  shall  not  stop  to  discuss  such  methods  as  the  inflation  of  a 
rubber  bulb  introduced  into  the  stomach  (Schreiber)  or  estimations 
by  means  of  the  manometer  (Purgecz),  but  finally  shall  consider 
the  diagnostic  value  of  the  measurement  of  the  stomach  by  filling 
it  with  water.  For  this  purpose  the  stomach  must  be  filled  as 
full  as  possible  and  then  be  entirely  emptied  ;  but  —  when  is  it 
full  ?  We  must  either  rely  on  the  statements  of  the  patients,  who 
generally  experience  a  distinct  sensation  when  the  stomach  begins 
to  be  more  markedly  filled,  or  w^e  must  wait  till  they  vomit  the 
superfluous  quantity  of  water.  ISTeither  sign  can  be  absolutely 
depended  upon,  since  the  point  in  question  varies  with  the  sensi- 
tiveness of  the  patient,  and  the  capacity  of  the  stomach  is  so  dif- 
ferent individually.  Therefore  we  can  only  speak  positively  of  an 
absolutely  large  stomach  when  its  capacity  is  more  than  1,500  c.  c. 
[f  §  1]  of  water. 

Etiology  of  Dilatation  of  the  Stomach. — Dilatations  of  the  stomach 
are  produced  by  two  etiological  factors  :  (1)  mechanical  stenoses  of 
the  pylorus,  (2)  ahsolute  or  relative  weakness  of  the  expulsive  forces 
— in  other  words,  atonic  conditions  of  the  muscularis.  It  is  self-evi- 
dent that  in  a  normally  acting  stomacli  the  relations  between  con- 
tents, muscular  action,  and  resistance  at  the  pjdorus  must  be  in  the 
proper  proportion ;  therefore  any  change  in  these  factors  must  lead 


ETIOLOGY  OF  GASTHECTASIS.  121 

to  a  disturbance  of  function,  wliich  in  most  cases  gives  rise  to  dilata- 
tion of  the  organ.  However,  the  requisite  relationship  may  be  pre- 
served by  compensation,  in  spite  of  abnormal  change  of  the  indi- 
vidual factors,  and  only  when  this  fails  do  we  get  functional  dis- 
turbance, just  as  in  cardiac  disease  there  is  no  circulatory  disturb- 
ance until  the  compensation  of  tlie  valvular  lesions,  etc.,  becomes 
inefficient.  Oser  *  has  already  made  use  of  this  explanation  as  the 
basis  of  his  discussion  of  gastric  dilatation,  and  it  will  also  be  suffi- 
cient for  us.f  For  the  purposes  of  com^jensation  the  organism  has 
hypertrophy  of  the  muscularis  at  its  disposal ;  however,  it  is  to  be 
remembered  that  only  rarely  does  the  hypertrophy  of  the  muscular 
layer  manifest  itself  in  an  appreciable  thickening,  but  that  as  a  rule 
it  is  not  recognizable,  since  the  individual  fasciculi  are  separated  and 
at  the  same  time  spread  out  by  the  dilatation  of  the  organ.  How- 
ever, if  under  such  circumstances  it  were  possible  to  conceive  of  the 
stomach  being  reduced  to  its  normal  size,  the  amount  of  muscular 
tissue  remaining  the  same,  we  would  find  this  layer  quite  markedly 
increased  in  thickness. 

In  order  to  gain  a  satisfactory  insight  into  the  nature  of  dilata- 
tion of  the  stomach  we  must  above  all  recognize  the  fact  that  we 
have  always  to  deal  with  a  consecutive  process,  a  symptom,  but  not 
with  an  independent  disease,  and  that  therefore  the  most  varied 
causes  may  be  involved,  as  long  as  they  call  into  existence  the  pre- 
liminary conditions  soon  to  be  spoken  of.  To  be  sure,  the  clinical 
picture  of  dilatation  of  the  stomach,  wdien  it  is  fully  developed,  is 
very  uniform,  and  so  marked  when  contrasted  with  this  diversity 
of  the  etiological  factors,  that  as  a  rule  it  predominates  and  more  or 
less  relegates  the  original  trouble  to  the  background.  Yet,  for  this 
very  reason,  it  becomes  our  imperative  duty  to  seek  for  the  cause 
in  every  case  of  dilatation  of  the  stomach,  especially  since  by  its 
recognition  the  prognosis  is  by  no  means  immaterially  influenced. 

*  L.  Oser.  Die  Ursachen  der  Magenerweiterung.  Wiener  med.  Klinik,  1881, 
No.  1. 

f  [Oser  has  graphically  represented  this  relation  in  the  formula  C  >  I  4-  W,  in 
which  C  =  contractility  of  the  stomach,  I  =  resistance  from  gastric  contents,  and 
W  =  resistance  at  pylorus.  The  results  of  disturbance  of  these  factors  in  causing 
dilatation  and  the  changes  which  are  necessary  to  maintain  the  normal  relations 
may  be  seen  at  a  glance. — Tr.] 


122  DISEASES  OF  THE  STOMACH. 

For,  according  to  the  character  of  this  causative  factor  will  there  be 
a  transient  or  permanent  condition,  a  reparable  or  an  irreparable 
disturbance.  We  must  therefore  differentiate,  as  I  have  already 
mentioned  at  the  opening  of  this  lecture,  between  functional  and 
organic  dilatations ;  i.  e.,  between  those  forms  of  dilatation  of  the 
stomach  which  do  not  result  in  a  material  lesion  of  the  motor  appa- 
ratus together  with  its  nerves — therefore  those  which  can  be  cured — 
and  those  in  which  the  circumstances  will  not  permit  such  a  result 
because  severe  degenerative  processes  have  develoj^ed  in  the  gas- 
tric wall.  But  at  times  the  functional  dilatations  may  even  arise 
acutely ;  at  any  rate,  they  are  always  of  relatively  short  duration, 
so  that  they  do  not  lead  at  all  to  the  classical  symptoms  of  dilatation 
of  the  stomach,  or  only  do  so  transiently ;  they  run  the  course 
rather  of  dyspeptic  conditions  peculiar  to  the  special  underly- 
ing disease  of  the  organ,  chronic  gastritis,  atony,  or  the  neuroses. 
Therefore  I  shall  defer  the  discussion  of  these  functional  or  repara- 
ble dilatations  until  I  come  to  treat  of  the  affections  just  mentioned. 

It  is  at  once  apparent,  however,  that  these  two  groups  are  not 
independent  of  each  other,  but  that  the  first  can  and  does  become 
transformed  into  the  second  when  the  causative  conditions  persist. 

Unfortunately,  the  latter  is  the  rule,  the  former  the  exception  ; 
for  in  the  majority  of  cases  we  are  unable  to  remove  the  primary 
cause  of  the  trouble  even  after  having  discovered  it,  partly  because, 
in  the  very  nature  of  the  matter,  we  can  only  recognize  the  con- 
dition when  it  has  reached  a  relatively  advanced  stage,  and  partly 
because  it  lies  beyond  our  power,  even  at  the  beginning,  to  eradicate 
the  causative  factor.  However,  if  the  latter  be  the  case,  if  we  suc- 
ceed in  removing  the  cause,  and  if  the  dilatation  has  not  become 
organic,  it  will  then  be  possible  to  cure  it.  This  seems  to  me  to 
have  been  proved  by  a  case  of  Klemperer,*  which  thus  far  is  the 
only  one  of  its  kind  in  literature.  It  was  as  follows :  Cicatricial 
stricture  of  the  j^ylorus,  produced  by  the  corrosive  action  of  hydro- 
chloric acid,  consecutive  dilatation  of  the  stomach  (capacity  2|  litres 
[O  vss.]),  operation  upon  the  stenosis,  cure  of  the  gastric  dilatation, 
so  that  several  months  later  the  stomach  of  the  patient,  who  died  of 

*  Klemplerer.    Verein  fiir  iunere  Medicin  in  Berlin.     Meeting  of  February  4, 
1889.     Deutsche  med.  Wochenschr.,  No.  9,  S.  170. 


ETIOLOGY   OF   GASTRECTASIS.  123 

plithisis  in  his  thirty-fifth  year,  although  large,  was  found  to  be  not 
truly  dilated. 

The  mechanical  factors  ichicli  lead  to  the  stenosis  or  occlusion 
of  the  pylc/rus  are  situated  either  in  the  wall  of  the  stomach  itself 
or  extend  to  it  from  without.  Among  the  most  frequent  causes  of 
the  former  class  and  of  prime  importance  are  carcinoma  and  cica- 
tricial contraction,  whether  this  be  due  to  direct  cicatrization  of  an 
ulcer,  or  produced  by  inflammatory  processes  following  ulcer  or 
phlegmonous  gastritis.  Under  the  former  circumstances  it  is  not 
necessary  for  the  carcinomatous  proliferation  to  surround  the  pylo- 
rus like  a  ring  ;  it  may  be  situated  above  the  pylorus  and  have  warty 
or  polypoid  excrescences,  which  force  themselves  into  the  orifice 
somewhat  like  a  cork.  I  observed  such  a  condition  in  a  case  in 
which  a  very  vascular  polypoid  tumor,  larger  than  a  walnut,  was 
situated  on  the  posterior  wall  of  the  stomach,  its  base  being  about 
3  centimetres  [1|-  inches]  above  the  pylorus,  and  which  during  life 
must  have  more  or  less  completely  occluded  the  passage  like  a  ball 
valve  according  to  its  vascularity ;  the  pylorus,  although  somewhat 
narrowed,  would  easily  admit  the  little  finger  (Fig.  16). 

Bernabel  *  reports  a  similar  case,  which  is  remarkable,  however, 
by  the  formation  of  true  pedunculated  polypi.  The  largest  was  6" 8 
centimetres  [2f  inches]  in  length,  and  was  situated  on  the  anterior 
wall  of  the  stomach,  5  centimetres  [2  inches]  above  the  pylorus.  In 
Cruveilhier  f  may  be  found  the  drawing  of  a  tumor,  about  the  size 
of  a  potato,  situated  in  the  duodenum  immediately  below  the  pylo- 
rus, which  must  have  had  the  same  effect  as  a  true  pyloric  stenosis. 
Unique  among  such  obstructions  is  the  case  described  by  Pertik,  j^ 
in  which  a  diverticulum  shaped  Kke  a  glove-finger  was  situated  in 
the  duodenum  at  the  level  of  Yater's  papilla,  which,  according  to 
the  degree  to  which  it  was  filled  by  the  chyme  coming  from  the 
stomach,  must  have  prevented  its  passage  through  the  duodenum. 

Congenital  stenosis  of  the  pylorus  may  also  be  included  among 


*  Bernabel.  Contribuzione  al  etiologia  del  vomito  mecanieo  da  polypo  gastrico. 
Rivist.  clin.  di  Bologna,  1882. 

f  Cruveilhier.     Anatomie  pathologique  du  corps  humain,     Livr.  4,  pi.  1. 

X  0.  Pertik.  Beitrag  zur  Aetiologie  der  Magenerweiterung.  Yirchow's  Arch. 
Bd.  114,  S.  437. 


124 


DISEASES  OF  THE  STOMACH. 


Fig.  16. — Very  vascular,  polypoid  tumor,  on  posterior  wall  of  stomacli,  li  inch  above  the 

pylorus. 


ETIOLOGY   OP  GASTRECTASIS.  125 

the  mechanical  constrictions ;  such  cases  have  been  described  by 
Landerer*  and  R.  Maier.f  There  may  be  either  a  round  or 
a  sHt-hke  contraction  of  the  ostium  pylori,  or  the  muscular  portion 
of  the  pylorus  may  be  hypertrophied,  and  the  pyloric  portion  of  the 
stomach  present  a  spherical  or  conical  appearance,  in  which  latter 
case  it  projects  into  the  duodenum  like  the  cervix  uteri  into  the 
vagina.  This  hypertrophy,  by  the  way,  can  readily  be  distinguished 
from  the  form  produced  by  chronic  catarrh  of  the  mucous  mem- 
brane. It  is  very  apparent  that  such  stenoses  may  cause  the  deveh 
opment  of  a  dilatation  as  soon  as  the  expulsive  power  of  the  pyloric 
portion  of  the  stomach  becomes  unable  to  overcome  them — in 
other  words,  as  soon  as  the  antrum  pylori  passes  from  the  stage 
of  hypertrophic  compensation  into  that  of  insufficiency.  When 
this  will  occur  depends  naturally  upon  individual  circumstances. 
While  in  these  cases  the  obstruction  to  the  emptying  of  the 
stomach  is  manifest,  in  other  cases  we  find  the  pylorus  patent  after 
death,  and  yet  have  dilatation  of  the  stomach,  for  which  the  factors 
of  absolute  or  relative  muscular  insufficiency,  soon  to  be  discussed, 
can  either  not  be  applied,  or  are  not  sufficient  to  account  for  it. 

Kussmaul :{:  has  shown  by  experiments  on  the  cadaver  that  with 
great  relaxation  of  the  abdominal  walls  the  pylorus  may  assume  a 
vertical  position  due  to  the  rotation  of  the  full  stomach,  and  at 
the  same  time  so  twist  and  compress  the  horizontal  portion  of  the 
duodenum  at  its  junction  with  the  stomach  that  not  a  drop  of 
fluid  can  escape  into  the  duodenum.  As  can  readily  be  understood, 
the  lumen  of  the  intestine  may  be  occluded  by  bending,  not  at  the 
pylorus,  but  somewhat  below  it,  where  the  horizontal  curves  into 
the  descending  portion ;  this  takes  j)lace  when  the  stomach  is  filled 
and  its  ligaments  relaxed,  so  that  it  drags  the  horizontal  portion  of 
the  duodenum  down  with  it.  If,  in  addition,  there  exists  a  con- 
stricting stenosis  of  the  pylorus,  then  dilatations  of  the  duodenum, 
in  the  form  of  ampullae,  may  be  added  to  the  dilatation  of  the 
stomach,  as    is  typically  depicted   in  the  accompanying  drawing, 

*  Ueber  angeborene  Stenose  des  Pylorus.     Inaug.  Diss.     Tubingen,  1879. 
f  R.  Maier.     Beitrage  zur  angeborenen  Pylorus-stenose.     Virchow's  Arch.,  Bd. 
cii,  S.  413. 
:|:  Loc,  cit. 


126 


DISEASES  OP  THE  STOMACH. 


taken  from  a  paper  bj  Calm,*  which  at  the  same  time  gives  a  good 
idea  of  the  position  of  the  stomach  in  marked  dilatation  (Fig,  17). 


Fig.  17. — Cancer  of  pylorus,  with  dilatation  of  stomach  and  duodenum.  Distance  of  the 
greater  curvature  from  the  symphysis  =  4  ctm.  [1§  inches].  Portion  of  the  oesophagus  in 
the  abdominal  cavity  =  4  ctm.  [1|  inches].  Length  of  lesser  curvature  =  10  ctm.  [4 
in  ches].  c  =  carcinoma.  ^  =  pancreas ;  it  has  sunk  behind  the  lesser  omentum  to  the 
level  of  the  second  lumbar  vertebra,  d  =  horizontal  portion  of  the  duodenum  ;  its  verti- 
cal portion  descends  to  the  pelvic  brim,    s  —  stomach. 

*  Cahn,     Ueber  antipei'istaltische  Magenbewegungen.     Deutsch.  Arch.  f.  klin^ 
Med.,  Bd.  xxxv,  S.  414. 


ETIOLOGY  OP   GASTRBCTASIS. 


127 


An  additional  factor  may  perhaps  be  found  in  tlie  following; : 
While  under  the  usual  circumstances  the  demarkation  of  the  pylo- 
rus from  the  duodenum  consists  only  in  a  slight  constriction 
or  incline,  but  passes  perfectly  smoothly  on  to  the  stomach, 
we  occasionally  find  an  actual  ring,  so  that  on  section  of  the 
stomach  the  pylorus  looks  as  though  a  cord  had  been  drawn 
underneath  the  mucous  membrane.  A  small  pouch  is  consequently 
formed  on  the  gastric  side  of  the  orifice,  which  may  easily  become 
dilated  from  the  pressure  of  food,  and  thus  gradually  lead  to  a 
true  dilatation.  Necessarily,  an  uncommonly  firm  closure  of  the 
pylorus  would  be  requisite  for  this  to  occur — i.  e.,  a  spasmodic 
contraction.  This  brings  me  to  the  last  cause  which,  situated 
within  the  stomach,  is  said  to  lead  to  gastric  dilatation  by  closure 
of  the  pylorus — the  spastic  contractions  of  this  orifice.  Such  a  con- 
dition was  very  obvious  in  the  case  on  which  Sanctuary  *  performed 
an  autopsy.  The  pylorus  was  quite  patent,  but  above  it  lay  an 
egg-shaped  ulcer,  surrounded  by  normal  mucous  membrane,  2^ 
inches  long  and  1  inch  wide,  the  irritation  of  which,  from  the 
movements  of  the  food,  evidently  produced  a  marked  spastic 
contraction  of  the  entire  pyloric  region.  A  pronounced  dilatation 
of  the  stomach  had  been  diagnosticated  during  life.  However,  of 
all  the  causes  which  have  been  brought  forward  to  account  for 
dilatation,  where  there  is  no  tangible  narrowing  of  the  pylorus, 
spastic  contraction  appears  to  me  to  be  the  most  doubtful ;  for  it 
lies  in  the  very  nature  of  spastic  contractions  that  they  do  not  per- 
sist continually,  but  relax  at  times — consequently,  that  they  can  not 
produce  any  lasting  obstruction.  According  to  our  present  ex- 
periences, which  appear  to  be  pretty  generally  recognized,  spasm 
of  the  pylorus  is  produced  by  excessive  acidity  of  the  stomach- 
contents  ;  according  to  this,  all  cases  of  hyperacidity  would  finallj^ 
have  to  lead  to  dilatation  of  the  stomach,  which,  at  least  as  far 
as  our  present  knowledge  goes,  is  surely  not  the  case.  Yet 
Germain  See  f  has  lately  expressed  the  view  that  a  very  definite 

*  Sanctuary.  Notes  of  Cases  of  Dilated  Stomach,  with  Remarks.  British  Med. 
Journal,  1883,  p.  613. 

f  Germain  See.  Hyperchlorhydie  et  Atonie  de  I'Estomac.  Bull,  de  TAcad.  de 
med.  Seance,  d.  1  Mai.,  1888. 


128  DISEASES   OF   THE  STOMACH. 

causal  interdependence  exists  between  hyperacidity — i.  e.,  increased 
secretion  of  liydrocliloric  acid — and  atony  of  tlie  stomacli,  which 
may  lead  to  its  dilatation.  Meanwhile,  his  cases  do  not  present 
the  picture  of  acute  gastric  dilatation,  with  its  classical  symptoms ; 
they  could  much  more  readily  be  included  among  the  functional 
dilatations,  in  so  far  as  the  question  of  dilatation  of  the  stomach  is 
concerned.  Yet  it  is  possible  that  the  condition  of  the  pylorus, 
just  mentioned,  in  such  spasms,  might  be  an  important  factor  in 
the  development  of  dilatation.  But,  should  we  ascribe  persistence 
to  such  a  spasmodic  closure  of  the  sphincter,  then  naturally  it  must 
in  time  lead  to  a  form  of  compensatory  hypertrophy  of  the  mus- 
cnlar  layer  at  the  pylorus ;  and  to  such  a  condition  the  cases  of  so- 
called  idiopathic  hypertrophic  stenosis  of  the  pylorus,  found  in 
literature,  are  probably  to  be  referred.  A  well-observed  case  of 
this  kind,  with  reference  to  the  final  result,  is  that  reported  by 
Nauwerk.* 

A  woman,  twenty -three  years  old,  had  sufPered  for  ten  months  with 
slight  dyspeptic  manifestations.  After  swallowing  some  cherry-pits  symp- 
toms of  closure  of  the  pylorus  suddenly  ajopeared,  continuous,  obstinate 
vomiting,  and  absolute  constipation.  Death  followed  three  months  later. 
The  muscular  layer  at  the  pylorus  was  found  to  be  7  millimetres  [J  inch] 
thick,  the  mucosa  4  to  5  millimetres  [|  inch],  the  serosa  2  millimetres  [j-V 
incli],  the  pyloric  orifice  being  quite  patent.  No  neoplasm  could  be  found 
either  on  macroscopic  or  microscopic  examination.  There  were  ten 
cherry-pits  still  present  in  the  enormously  dilated  stoinach.  According  to 
our  present  ideas,  we  would  be  compelled  to  regard  this  hypertrophy  as 
having  been  caused  by  hypersecretion  of  acid. 

The  causes,  situated  external  to  the  stomach,  which  may  lead  to 
stenosis  or  occlusion  of  the  pylorus,  are  either  tumors  which  exert 
pressure  upon  the  pyloric  orifice  (or  the  duodenum),  or  which  em- 
brace and  grow  around  it ;  such  neo]3lasms  arise  either  from  the 
pancreas,  the  omentum,  the  retroperitoneal  glands,  or  the  liver. 
]VIinkowski  f  reports  a  rare  occurrence  of  this  kind  in  which  he 
observed  a  hard  tumor  which  was  considered  a  cancer  of  the  pylo- 
rus during  life,  combined  with  dilatation  of  the  stomach,  but  which 

*  Nauwerk.  Ein  Fall  hypertrophischer  Pylorusstenose  mit  hochgradiger  Ma- 
generweiterung.     Deutsch.  Arch.  f.  klin.  Med.     Bd.  xxi,  S.  573-580. 

f  0.  Minkowski.  Ueber  die  Gahrungon  im  Magen.  Mittheilungen  aus  der  med. 
Klinik  zu  Konigsberg  in  Preussen,  S.  168. 


ETIOLOGY   OF   GASTRECTASIS.  129 

after  death  was  found  to  be  the  gall-bladder  entirely  filled  by  a 
large  calculus ;  this  compressed  the  pylorus  completely  and  led  to 
the  enormous  dilatation.  In  this  case  examination  for  liydrochloric 
acid  would  have  definitely  excluded  carcinoma,  even  though,  as  we 
shall  see  later,  this  is  not  positive ;  at  any  rate,  it  is  at  times  abso- 
lutely impossible  to  differentiate  between  tumors  of  the  liver  or 
gall-bladder,  or  biliary  calculi  and  neoplasms  of  the  stomach.  Fur- 
ther, if  an  old  peritonitis  gives  rise  to  cicatricial  bands  which  sur- 
round the  pylorus  or  force  it  toward  the  posterior  abdominal  walls, 
and  make  traction  upon  or  bend  the  pylorus — or  the  horizontal 
portion  of  the  duodenum — we  may  also  get  pyloric  stenosis.  Roki- 
tansky  *  has  seen  cases  of  gastrectasis  which  were  caused  by  large 
scrotal  hernise  exerting  traction  upon  the  stomach  and  dislocating 
it  (and  possibly  also  bending  the  duodenum  ?)  Bartels  was  the  first 
to  call  attention  to  the  joint  occurrence  of  wandering  kidney  on  the 
right  side  and  dilatation  of  the  stomach,  accounting  for  the  latter 
by  the  pressure  made  by  the  kidney  upon  the  duodenum ;  this 
form  can  not  become  marked  unless  its  existence  dates  from  child- 
hood. Malbrancf  agrees  with  him,  and  Schiitz :{:  reports  the  case 
of  a  woman  whose  difiiculties  rapidly  disappeared  on  leaving  off 
her  corsets,  which  were  supposed  to  have  exerted  pressure  on  the 
dislocated  kidney.  Furthermore,  Litten  has  called  special  attention 
to  the  connection  between  diseases  of  the  stomach  and  change  in 
position  of  the  right  kidney,*  and  has  seen  displacement  of  the 
right  kidney  and  dilatation  of  the.  stomach  occurring  together  in 
no  less  than  55  per  cent  of  his  cases.  In  common  with  Bartels  he 
regards  the  dilatation  as  the  primary  trouble,  and  the  wandering 
kidney  as  secondary  to  it ;  while  I  agree  with  Oser,  IS^othnagel,  and 
Leube,!  and  wish  to  emphasize  the  fact  that  no  causal  relation  exists 
in  the  majority  of  cases,  but  that  it  is  a  simple  coincidence.  Fur- 
thermore, in  this  question  we  must  distinguish  between  the  simple 

*  Rokitansky.     Handbuch  der  pathol.  Anatomie,  Bd.  ii,  S.  178. 

f  Malbrane.  Ein  complicirter  Fall  von  Magenerweiterung.  Berl.  klin.  Woch- 
enschr.,  1880,  No.  28. 

I  E.  Schiitz.  Wanderniere  und  Magenerweiterung.  Prager  medicin.  Woch- 
enschr.,  1885.     January  14th. 

*  Verhandlungen  des  Congresses  fiir  innere  Medicin.     Wiesbaden,  1887,  S.  223. 
I  Loo.  cit.,  S.  225. 


130  DISEASES   OF   THE    STOMACH. 

palpable  and  tlie  true  wandering  kidney.  Among  seven  cases  of 
movable  and  displaced  riglit  kidnej — i.  e.,  true  wandering  kidney — 
whicli  Brentano  was  able  to  collect  in  a  few  weeks  in  tlie  poli- 
clinic of  tlie  Augusta  Hospital,  three  women  bad  gastric  dilatation ; 
among  twelve  cases  of  simple  palpable  kidney  there  was  only  one 
without  dilatation  of  the  stomach.  I  can  thus  confirm  the  fact  that 
a  movable  right  kidney  and  dilatation  of  the  stomach  frequently  oc- 
cur, especially  in  women,  without  on  that  account  agreeing  with 
Bartels,  who  believes  that  on  deep  inspiration  the  kidney  is  forced 
down  by  the  liver,  when  at  the  same  time  a  narrowing  of  the  lower 
half  of  the  thorax  also  exists,  and  that  the  duodenum  is  compressed 
between  the  liver  and  the  kidney.  To  bring  this  about  the  kidney 
would  necessarily  have  to  be  fixed  ;  but  its  characteristic  is  just  its 
mobility  ;  hence  it  slips  away,  and  it  is  only  necessary  to  have  seen 
in  an  animal  how  energetically  the  intestinal  contents  are  forced  on 
to  appreciate  how  easily  such  an  obstruction  could  be  overcome.  I 
think  Landau  *  is  right  when  he  says  that,  even  for  physical  reasons, 
the  kidney  would  be  unable  to  exert  the  necessary  pressure  on 
the  gut. 

The  second  great  group  of  dilatations  of  tlie  stomach  arises 
from  weakness  of  the  gastric  muscle,  and  differs  from  that  first 
spoken  of  in  that  as  a  rule  the  stomach  is  dilated  only  to  a  slight 
degree,  while  the  hypertrophy  of  the  muscularis  is  absent.  I 
shall  describe  these  conditions  as  atonic  gastric  dilatations  caused 
by  asthenia  or  akinesis  \_a,  without  KLveco,  I  move\  f  of  the  stom- 
ach. Predisposing  factors  are  :  1.  Weakening  of  the  muscidar  tone^ 
due  either  to  excessive  demands  (perhaps  traumatisms  ?)  upon  the 
muscle  and  its  gradual  relaxation,  or  to  insufficient  nourishment  of 
the  contractile  elements  of  the  gastric  wall  in  anaemia,  chlorosis, 
nervous  affections,  acute  and  chronic  diseases  of  an  exhausting  na- 
ture, peritonitis,  amyloid  degeneration  of  the  vessels.     Thus  we  find 


*  Landau.     Die  Wanderniere  der  Frauen.     Berlin,  1881,  S.  44. 

f  The  ancients  called  conditions  of  this  kind  frigiditas  stomachi.  Todd  was 
probably  the  first  to  use  the  term  atony ;  Andral  introduced  the  phrase  dyspepsie 
par  asthenie  de  Vestomac  ;  Broussais  designated  it  dyspepsie  asthenique.  The  most 
varied  dyspeptic  conditions  were  included  under  this  term. 


ETIOLOGY   OF  GASTRECTASIS.  131 

tliat  clironic  gastric  catarrh  must  also  be  included  among  the  etio- 
logical factors  of  dilatation  of  the  stomach.  Since  the  catarrhal 
condition  causes  the  ingesta  to  remain  for  a  longer  time  than  normal 
in  the  stomach,  it  is  overburdened,  and  a  relaxation  of  the  muscle 
is  produced,  which,  as  we  shall  see  when  speaking  of  atrophy  of  the 
stomach,  finally  leads  to  separation  of  the  fibers  of  the  submucosa 
and  muscularis ;  dilatation  of  the  organ  is  the  result,  just  as  the 
bladder,  when  afiiected  with  catarrh,  finally  becomes  the  seat  of 
paralytic  dilatation.  It  is  in  this  sense  that  we  must  understand 
Cloizier  *  when  he  includes  deficient  hygiene  in  combination  with 
continual  erect  position  of  the  body  among  the  causes  of  dilatation 
of  the  stomach. 

The  excessive  tension  of  the  walls  of  the  stomach  is  not  only 
brought  about  by  overloading  the  stomach  with  improper  quantities 
of  solid  masses,  with  which  the  muscle  is  unable  to  cope,  but  also 
by  the  abnormal  production  of  gases  in  the  stomach,  together  with 
closure  of  the  orifices ;  the  latter  may  be  of  a  mechanical  nature 
from  the  commencement,  and  due  to  one  of  the  aforementioned 
factors,  or  may  be  due  to  the  occurrence  of  an  abnormal  fermentation 
of  the  ingesta,  which  only  leads  secondarily  to  muscular  insufficiency. 
As  Miller's  f  experiments  have  proved,  and  as  daily  experience  con- 
firms, such  primary  fermentations  will  always  arise  whenever  an 
improper  proportion  exists  between  the  micro-organisms  which  are 
present  or  which  are  introduced  into  the  stomach,  and  the  amount 
of  hydrochloric  acid,  Avhich  normally  has  an  antiferinentative 
action  ;  thus  too  many  zymotic  organisms  may  be  introduced  while 
the  quantity  of  hydrochloric  acid  secreted  is  normal,  or  the 
latter  may  not  be  enough  for  their  disinfection.  As  we  know  best 
from  our  observations  upon  the  intestines,  the  products  of  fermen- 
tation, when  absorbed,  cause  an  irritation  of  the  muscle,  which,  as 
long  as  the  contractibility  is  intact,  probably  leads  also  to  the  simul- 
taneous closure  of  the  sphincters,  and  in  this  way  causes  an  abnor- 

*  Cloizier.  De  la  dilatation  dite  primitive  de  I'estomae.  Bull,  med.,  1888,  p. 
124o. 

f  Miller.  Einis:e  gasbildende  Pilze  des  Verdauungstraetus,  ihr  Schicksal  im 
Magen  und  ihre  Reaction  auf  verschiedene  Speisen.  Deutsche  med.  Wochenschr., 
1866,  No.  8. 


133  DISEASES  OF  THE  STOMACH. 

mally  long  detention  of  the  fermenting  masses  in  the  stomach. 
Later,  owing  partly  to  mechanical  distention,  partly  to  the  venous 
stasis  intimately  connected  thercM-ith,  structural  changes  are  pro- 
duced in  the  mucosa  and  muscularis ;  also  paresis  and  degeneration, 
and  thus,  finally,  muscular  insufficiency  of  the  organ.  Thus  it  is 
that  we  find  dilatation  of  the  stomach  so  frequently  in  gluttons, 
diabetics,  insane  patients  with  polyphagia,  etc. ;  it  may  also  develop 
from  chronic  gastric  catarrh,  or  (probably  most  frequently)  it  may 
arise  from  a  combination  of  both  causes.  It  is  especially  due  to 
I^aunyn,  *  and  his  pupil  Minkow"ski,f  that  these  processes  have  been 
properly  considered. 

2.  Weakness  and  paralysis  of  the  motor  nerve-fibers  of  the 
stomach,  or  diminished  excitability  of  the  nervous  apparatus,  pre- 
siding over  peristalsis,  may  be  caused  by  local  lesions,  such  as 
destruction  by  ulceration  of  the  branches  of  the  vagus  entering 
the  stomach  (Traube),  or  by  processes  of  inhibition  arising  from 
other  portions  of  the  nervous  system  —  for  instance,  the  para- 
lyzing influence  exerted  by  chronic  peritoneal  exudations  (Bam- 
berger), or  even  by  a  simple  catarrh  of  the  stomach,  just  as 
paralyses  of  the  muscles  of  the  vocal  cords  are  produced  by  lar- 
yngeal catarrh.  Perhaps  it  is  here  that  we  must  include  those 
rare  cases  of  atonic  dilatation  of  the  stomach  which,  quite  con- 
trary to  the  ordinary  course  of  events,  develop  as  the  result  of 
chronic,  obstinate  constipation,  when,  as  a  rule,  just  the  opposite 
occurs.  AVe  know  that  there  is  no  sharp  line  of  demarkation  be- 
tween the  peristalsis  of  the  intestines  and  that  of  the  stomach,  but 
that,  rather,  the  peristalsis  of  the  upper  portion  of  the  intestines  can 
be  obliterated  by  the  contractions  of  the  stomach,  as  Braam-Houck- 
geest  "^  has  shown.  Inversely,  persistent  sluggishness  or  paresis 
of  the  intestines  might  give  rise  to  diminished  peristalsis  in  the 
stomach.     Gr.  See  and  Mathieu  *  have  also  called  attention  to  this 


*  B.  Naunyn.  Ueber  das  Verhaltniss  der  Magengahning  zur  mechan.  Magenin- 
sulflcieiiz.     Deutsch.  Arch.  f.  Idin.  Med.,  Bd.  xxxi,  S.  225. 

f  Minkowski,  Joe.  cit. 

X  Ewald,  Klinik  etc.     I.  Theil.,  3.  Aufl.,  S.  192. 

*  G.  See  et  Mathieu.  De  la  dilatation  atoniqiie  de  Testomac.  Rev.  de  med., 
1884,  10  Mai,  10  Sept. ;  and  A.  Mathieu.  Les  phenomenes  nervo-moteurs  de  la 
dyspepsie  gastrique.     Gaz.  d.  hopit.,  1888,  No.  47. 


PATHOLOGY  OF  GASTRECTASIS.  133 

point.  I  saw  a  very  convincing  example  of  tliis  in  a  lady  thirty 
years  of  age,  who  had  suffered  with  obstinate  constipation  since 
childhood  (the  trouble,  as  is  not  at  all  infrequent,  was  hereditary  in 
her  family),  and  who,  in  the  course  of  my  observations,  extending 
over  a  period  of  two  years,  although  she  had  never  before  com- 
plained of  stomach  trouble,  acquired  a  typical  dilatation  of  tlie 
stomach,  without,  it  is  true,  any  marked  signs  of  decomposition,  but 
yet  without  any  other  referable  cause. 

3.  Finally,  the  expulsive  powers  may  be  weakened  by  the  ex- 
clusion of  a  more  or  less  sTiwr^ly  hounded  portion  of  the  muscular 
fibers  of  the  stomach.  Circumscribed  canceroiis  infiltration  and 
ulcerations  which  do  not  stenose  the  stomach  but  destroy  a  portion 
of  its  muscle,  result  at  times,  if  their  growth  be  slow  enough,  in 
hypertrophic  dilatation  of  the  stomach.  A  similar  condition  is 
produced  when  broad  bands  of  the  muscular  layer  of  the  stomach 
are  destroyed  by  inflammatory  or  ulcerative  processes,  and  cause 
partial  dilatation  behind  the  site  of  the  obstruction  or  complete 
gastrectasis.  Yery  instructive  pictm-es  of  this  process  may  be  seen 
in  Cruveilhier's  celebrated  atlas  of  pathological  anatomy.* 

This,  as  far  as  I  can  see,  exhausts  the  etiology  of  dilatations  of 
the  stomach.     I  shall  now  turn  to  the 

Pathology. — I  have  already  spoken  of  the  gross  anatomical 
changes,  the  variations  in  the  size  of  the  dilated  stomach,  and  the 
changes  in  the  position  of  the  neighboring  organs  produced  there- 
by— the  intestines  being  forced  into  the  pelvis,  while  the  liver, 
spleen,  and  diaphragm  may  be  displaced  upward — as  well  as  the 
nature  and  shape  of  possible  neoplasms,  to  which  I  shall  again 
revert  when  discussing  the  symptoms  of  the  disease.  At  present 
the  changes  in  the  individual  coats  of  the  stomach  are  of  special 
importance.  It  has  been  known  for  a  long  time  that  the  muscu- 
laris  may  be  totally  or  partially  thickened,  or  apparently  normal  or 
thinned ;  a  distinction  has  thus  been  made  between  hypertrophic 
and  atrophic  forms.  Hypertrophy  of  the  muscularis  preponder- 
ates in  the  pyloric  region,  and  occurs  most  frequently  with  can- 
cerous or  cicatricial  stricture  of  the  pylorus.    Whether  in  such  cases 

*  [Anatomie  pathologique  du  corps  humain.     Paris,  1830-1843,  2  vols. — Tr.J 


134  DISEASES   OF  THE  STOMACH. 

there  is  a  true  liypertropliy,  or  only  an  apparent  tliickening  of  the 
muscular  wall  of  the  stomach,  on  account  of  infiltration  with  can- 
cerous elements,  can  frequently  be  decided  only  by  careful  micro- 
scopic examination.  But  at  times  we  find  the  muscle  at  the  pylorus 
hypertrophied,  without  the  j)resence  of  any  manifest  neoplasm  or 
cicatrix,  and  Lebert*  claims  to  have  found  an  increase  in  the 
thickness  to  l-i  millimetres  \_-^  inch] — generally  it  amounts  to 
5  to  6  millimetres  [|-  inch],  which  is  already  considerable ;  this  he 
regards  as  the  result  of  a  chronic  hypertrophic  inflammation  of  the 
muscularis,  j)roduced  idiopathically,  and  not  by  cancerous  infilti'a- 
tion  of  the  muscle.  There  can  be  no  doubt  that  the  hypertrophic 
form  may  gradually  pass  into  the  atrophic.  The  former  occurs 
more  frequently  in  youthful  individuals,  the  latter,  without  ex- 
ception, in  the  aged  ;  so  that  in  the  numerous  cases  of  dilatation  of 
the  stomach  in  old  people  on  whom  I  have  performed  autopsies  I 
have  never  found  hypertrophy  of  the  muscularis,  it  being  much 
oftener,  in  fact  in  the  majority  of  cases,  of  normal  tliickness,  and 
far  less  frequently  thinned.  The  individual  muscle-fibers  are  nor- 
mal in  appearance  ;  the  nuclei  stain  well  with  picro-carmine.  Since 
1874:  I  have  examined  a  large  number  of  dilated  stomachs  micro- 
scopically, but  I  have  never  found  hypertrophy  of  the  individual 
muscle-cells,  of  which  Lebert  speaks,  nor  degeneration  of  these  cells 
into  a  gelatinous  mass  (colloid  degeneration),  as  described  by  Kuss- 
maul  and  K.  Meyer,  and  recently  also  found  by  Calm ;  while 
frequently  there  existed  a  more  or  less  extensive  fatty  degener- 
ation. The  interspaces  between  the  individual  muscular  fasciculi 
appear  enlarged  and  traversed  by  strands  of  connective  tissue. 
Yery  often  an  infiltration  of  small  cells  is  present,  proceeding 
from  the  submucosa.  The  latter  forms  a  wide-meshed  tissue 
studded  with  numerous  round  cells,  and  its  vessels  widely  dilated. 
The  mucous  membrane  presents  the  picture  of  chronic  gastritis 
in  its  different  stages.  In  the  glandular  cells  of  the  mucosa  there 
is  no  change  at  all  in  many  places  ;  in  others  they  are  markedly 
cloudy  and  granular ;  in  still  others  they  show  cystic  degeneration, 
or  have  entirely   disappeared  in  a  round-celled  infiltration,  which 

*  Lebert,  loc.  cit.,  pp.  525  et  seq. 


PATHOLOGY   OF   GASTRECTASIS. 


135 


also  fills  and  foi'ces  tlie  meslies  of  tlie  interstitial  tissue  apart.  ]^o- 
wliere  can  we  recognize  that  tliey  are  hypertrophied.  Neither  do 
they  appear  to  be  increased  in  number.  The  interstitial  tissue  is 
considerably  thickened  and  studded  with  numerous  round  cells ; 
those  ducts  of  the  glands  which  are  present  are  forced  apart  and 
separated  by  wide  intervals,  while  normally  they  lie  close  together 
(Fig.  18),     I  have  never  found  conditions  which  pointed  to  new 


Fig.  18. — Cross-section  through  the  mucous  membrane  of  a  dilated  stomach.  The  ducts  of 
the  glands  are  forced  apart,  the  interstices  entirely  tilled  by  an  infiltration  of  small 
cells.  The  glandular  epithelium  is  unchanged  in  part,  partly  fatty,  and  in  some  places 
entirely  gone.  Single  epithelial  cells  may  be  seen  in  the  interstitial  tissue. — Camera 
lucida. 

formation  or  increase  (hyperplasia  or  hypertrophy)  of  the  glandu- 
lar substance.  In  the  great  majority  of  cases  the  mucous  mem- 
brane is  spread  smoothly  over  the  muscularis,  and  is  thinned  rather 
than  thickened;  yet  in  the  rare  forms  of  hypertrophic  dilatation 
the  condition  which  the  French  call  etat  niaramelone  is  developed, 
owing  to  the  unequal  growth  of  the  mucosa  and  the  muscularis, 
which  leads  to  the  former  being  thrown  up  into  folds. 

At  first  the  dilatation  of  the  stomach  is  found  specially  at  the 
cul-de-sac  i  later  on  it  involves  the  whole  organ,     A  pathological 


136  DISEASES   OP   THE   STOMACH. 

curiosity  are  tlie  rare  dilatation-like  diverticula  wliicli  are  due  to 
the  persistent  pressure  of  indigestible  substances  (coins,  etc.),  in  tlie 
stomach. 

Symptoms  of  Gastrectasis. — As  a  rule,  patients  with  dilatation  of 
the  stomach,  as  may  be  inferred  from  the  nature  of  its  causes,  are 
middle-aged  or  advanced  in  years.  Yet  the  more  extensive  my 
experience  becomes  the  more  am  I  astonished  at  the  frequency  with 
which  it  occurs  in  younger  persons,  and — is  not  recognized.  Ac- 
cording to  Pauli,*  stenosis  of  the  pylorus  may  be  congenital  and 
may  give  rise  to  dilatation.  Andral  f  sjjeaks  of  children  being  born 
with  stomachs  which  filled  the  greater  portion  of  the  abdominal 
cavity.  Similar  observations  have  frequently  been  made,  and  only 
a  short  time  ago  at  the  jDoliclinic  I  found  a  marked  dilatation  of 
the  stomach  in  a  girl  eighteen  years  of  age,  who  claimed  to  have 
heard  succussion  sounds  (which  were  very  evident  at  the  examina- 
tion) since  her  earliest  childhood.  In  the  last  year  and  a  half,  in 
my  own  practice,  I  have  seen  five  cases  of  considerable  and,  in  part, 
very  marked  gastric  dilatation  in  young  people  between  the  ages  of 
fifteen  and  twenty-one — one  a  farmer's  lad,  one  a  pupil  at  the  gym- 
nasium, and  three  students.  In  only  one  had  the  trouble  been 
recognized,  the  others  having  been  treated  for  "  chronic  dyspepsia  " 
or  "  nervous  dyspepsia,"  and  in  none  could  a  manifest  cause  for  its 
origin  be  made  out.  "Wiederhofer,:|:  Comby,  *  Malibran,  |j  and 
others  have  demonstrated  and  carefully  studied  dilatation  of  the 
stomach  in  children  which  they  have  ascribed  to  atonic  and  anaemic 
conditions. 

Before  speaking  of  the  symptomatology  of  dilatation,  let  me 
state  that  we  not  so  very  rarely  see  cases  >\diich  present  the  typical 
clinical  picture  of  gastric  dilatation  as  I  am  about  to  describe  it  to 
you,  and  yet  in  which  there  is  no  true  dilatation  of  tlie  stomach. 


*  Pauli.     De  ventriculi  dilatatione.     Frankfurt  a.  M.,  1839. 

\  Andral.     Grundriss  der  pathol.  Anatomie.     Edited  by  Becker,  1830,  ii,  S.  91. 
if  Wiederhofer.     Gerhardt's  Handb.  d.  Kinderkrankheiten.     Bd.  W,  Abtheil.  ii,  S. 
356  et  seq. 

*  Comby.     De  la  dilatation  de  Testomac  chez  les  enfants.     Arch,  gener.  de  med., 
Aout  et  Sept.,  1884. 

I  Malibran.     Contribution   a  I'etude  des  ectasies  gastriques.     These  de  Paris, 
1885. 


VOMITING  IN  GASTRECTASIS.  137 

I  shall  designate  such  cases,  as  O.  Eosenbach  has  done,*  gastric 
insuffiyciency^  or  better,  irnotor  insujficiency  of  the  stomach.  I  sliall 
again  refer  to  this  in  the  coui'se  of  my  remarks  on  the  symptom- 
atology. 

The  symptoms  of  dilatation  of  the  stomach  always  develojD 
slowly.  As  a  rule,  dyspeptic  troubles  are  the  first  to  appear,  and 
they  may  last  for  years ;  indeed,  they  may  be  the  only  symptom  of 
an  already  developed  dilatation.  Thus  it  is  that  the  latter  is  dis- 
covered only  on  a  very  careful  examination  of  the  patient ;  this 
occurred  to  me  only  lately  in  a  young  man  whose  father,  a  physi- 
cian, had  given  him  a  letter  with  an  explicit  description  of  the 
symptoms  on  wdiich  he  had  based  the  diagnosis  of  nervous  dyspep- 
sia. In  addition  to  the  dyspeptic  difficulties — anorexia,  pressure 
and  fullness  after  eating,  tension  of  the  abdomen,  bad  odor  from  the 
mouth,  coated  tongue,  epigastric  tenderness,  malaise,  oppression 
and  pain  in  the  head,  irregular  stool,  etc. — we  have  a  characteristic 
symptom  in  vomiting.  At  first  this  occurs  frequently  and  com- 
paratively soon  after  eating,  being  to  a  certain  extent  a  therapeutic 
effort  of  the  organism  to  relieve  itself  of  the  excess  of  the  ingesta, 
while  a  portion  is  retained  in  the  stomach,  as  urine  is  in  a  paralyzed 
bladder.  Later  the  vomiting  occurs  less  frequently  in  proportion 
to  the  increasing  relaxation  of  the  muscle  and  as  the  quantity  of 
the  collected  masses  to  be  evacuated  becomes  greater  ;  finally — and 
this  is  always  a  bad  omen — it  ceases  entirely.  Then  either  the 
obstructing  neoplasm  has  ulcerated,  thus  again  opening  the  pas- 
sage into  the  intestine,  or  a  complete  paralj^sis  of  the  muscle  has 
been  developed.  A  characteristic  feature  of  the  vomit  is  its  large 
quantity,  which  in  individual  cases  has  been  quite  astonishing,  and 
is  said  to  have  been  as  much  as  8  kilogrammes  [lYf  pounds]  !  Por- 
tal says  that  the  stomach  of  the  Due  de  Chausnes,  one  of  the  great- 
est gourmands  in  Paris,  could  hold  eight  pints  of  fluid  ;  and  even 
larger  figures  are  given.  It  is  well  known  that  at  times  more  is 
vomited  than  has  been  eaten,  since  the  remnants  of  former  meals 
which  accumulate  in  the  stomach  for  a  longer  time  are  added.  If  the 
vomit,  or  the  masses  removed  from  the  stomach  through  the  tube, 

*  0.  Rosenbach.  loc.  cit. 


138  DISEASES  OP  THE  STOMACH. 

are  allowed  to  stand  in  a  glass  cylinder,  tliey  soon  separate  into 
three  layers,  the  upper  one  of  brownish  foam,  a  much  laj-ger  mid- 
dle layer  of  yellowish-brown,  faintly  cloudy  fluid,  and  a  lower  one 
consisting  of  dark-brown,  crummy,  and  slimy  masses,  chiefly  remains 
of  food.  From  time  to  time  bubbles  of  gas  rise  up  through  the 
fluid,  carrying  particles  of  the  deposit  with  them,  while  other  frag- 
ments sink,  since  they  are  no  longer  supported  by  the  carbonic-acid 
gas.  Such  a  play  of  bubbles,  similar  to  that  which  we  see  in  a  glass 
of  champagne  in  which  bread-crumbs  have  been  placed,  always  indi- 
cates considerable  yeast  fermentation.  Further,  we  find  the  ingre- 
dients of  the  food  in  the  vomit  in  a  more  or  less  softened  and 
digested  condition ;  we  also  find  varieties  of  mucor,  sarcinse,  yeast, 
and  numberless  schizomycetes.  At  Kussmaul's  suggestion  Du 
Barry  *  examined  these  vegetable  forms  more  carefully,  and  isolated 
them  in  pure  cultures,  but,  it  is  to  be  regretted,  without  obtaining 
any  definite  pathognostic  result.  We  are  not  justified,  from  the  ob- 
servations made  by  this  author,  in  inferring  a  fermentative  action 
from  the  presence  and  growth  of  the  fungi ;  at  all  events,  bacteria, 
yeast,  and  probably  sarcinse  also  have  a  definite  typical  fermentative 
action.  Sarcinae  ventriculi,  those  peculiar  colonies  of  cocci  which 
occur  in  cubes  or  as  tetrads,  were  first  described  by  Goodsir  in 
1842 ;  the  extensive  literature  which  has  been  written  about  them 
since  then  has  been  collected  in  detail  by  Falkenheim.f  It  is  a 
matter  of  regret  that  the  pathognostic  significance  of  this  parasite 
does  not  deserve  the  interest  which  was  accorded  to  it  by  physi- 
cians. As  early  as  1849  Frerichs  apologized  for  speaking  about 
a  subject  "  the  literature  of  which  is  perhaps  more  extensive  than 
its  importance  warrants " ;  thus  Falkenheim  also  was  unable  to 
add  anything  new  as  to  their  occun-ence  or  significance,  while  he 
established  the  important  fact  in  the  natural  history  of  sarcinse  that 
at  times,  according  to  external  circumstances,  the  same  cocci  may 
form  either  irregular  masses  or  typical  sarcinse.  Usually  sarcinse 
are  present  in  small  numbers  or  are  entirely  absent,  yet  at  times  in 
conditions  favorable  to  their  growth  they   may  appear   in   large 

*  Du  Barry.     Beitrag  zur  Kenntniss  der  niederen  Organismen  im  Mageninhalt. 
Arch.  f.  exp.  Pathol,  u.  Pharmacol.,  Bd.  xx,  S.  243. 

f  Falkenheim.     Ueber  Sarcine.     Arch.  f.  exp.  Pathol,  u.  Pharmacol.,  Bd.  xix. 


FERMENTATIONS  IN  GASTRECTASIS.  130 

masses,  so  that  every  drop  of  stomacli-contents  is  really  a  pure 
culture  of  them ;  indeed,  F.  Eichter  *  reports  a  case  in  which 
the  inspissated  masses  of  sarcinse  had  led  to  complete  closure  of  the 
pylorus. 

But  if,  as  I  have  said  above,  Du  Barry  was  unable,  with  few  ex- 
ceptions, to  refer  definite  processes  of  fermentation  to  individual 
fungi  isolated  from  the  contents  of  the  stomach,  their  active  par- 
ticipation as  a  whole  is  by  no  means  excluded  thereby,  nor  is  it 
proved  that  their  occurrence  is  insignificant  and  unimportant.  I 
agree  entirely  with  Minkowski  f  that  their  presence,  as  soon  as 
they  appear  in  larger  numbers,  invariably  permits  us  to  conclude 
that  there  exists  a  severe  disturbance  of  the  chemical  functions,  and 
that  therefore  the  proof  of  their  presence  in  the  stomach-contents 
is  not  to  be  disregarded.  The  microscope  discloses  the  presence, 
and  in  part  also  the  variety,  of  the  individual  organisms ;  we  may 
examine  either  the  masses  directly  vomited  or  the  aspirated  stomach- 
contents,  or  its  fresh  filtrate.  "  In  those  cases  in  which,  at  the 
height  of  digestion,  or  some  time  after  the  ingestion  of  food,  large 
numbers  of  fungi  or  bacteria  are  found  in  the  stomacli-contents, 
on  microscopic  examination,  we  may  assume  the  existence  of  mor- 
bid gastric  fermentation,"  says  Minkowski ;  but  he  immediately 
adds  that  the  view  of  what  is  meant  by  "  large  numbers "  is  sub- 
ject to  considerable  uncertainty.  For  a  few  fungi  can  be  found 
even  in  tlie  contents  of  the  healthiest  stomach,  where,  indeed,  they 
have  no  importance,  since,  as  I  have  said  above,  their  development  is 
checked  by  the  hydrochloric  acid.  This  can  be  seen  from  the  fact 
that  the  filtrate  of  normal  stomach-contents  may  stand  exposed  for 
weeks,  and  even  for  months,  without  becoming  cloudy  or  moldy, 
unless  spores  fall  in  from  without.  However,  if  large  numbers  of 
micro-organisms  are  present  in  the  stomach-contents,  in  spite  of 
the  free  hydrochloric  acid,  or  if  their  reaction  be  neutral,  or  if 
the  acidity  be  due  to  organic  acids,  there  is  immediately  such  a 
development  of  fungi  in  the  filtrate  that  the  variety  of  the  pre- 
dominating fermentation  may  be  recognized  even  by  mere  inspec- 

*  Riehter,    Verstopfung  des  Pylorus  durch  Sarcina  ventriculi.    Virehow's  Arch., 
Bd.  cvii,  S.  198. 

f  Minkowski,  loc.  cit. 
10 


J 40  DISEASES   OF   THE  STOMACH. 

tion.  Thus  we  may  find  mold  fungi — and  this  even  in  the  presence 
of  the  hydrochloric-acid  reaction  in  the  filtrate — in  the  form  of  a 
white  or  gray  scum  upon  the  surface  ;  or,  after  being  cloudy  at  first, 
yeast  may  be  deposited  at  the  bottom  of  the  vessel;  or  a  more 
equally  diffused  turbidity,  together  with  a  strong  sour  odor,  may 
be  produced  by  the  development  of  the  lactic,  acetic,  and  butyric 
acid  fungi ;  or,  finally,  white  zooglea  masses,  which  readily  fall  apart, 
may  form  upon  the  surface ;  these  finally  lead  to  complete  decompo- 
sition of  the  albumen,  and  to  an  alkaline  reaction,  the  process  being 
accompanied  by  the  odor  of  decay.  In  this  way  we  can  in  a  given 
case  come  to  a  fairly  rapid  approximate  conclusion  as  to  the  pre- 
dominant fermentation  fungi,  provided  we  are  sure  that  they  have 
not  gained  access  thereto  post  festum — i.  e.,  from  the  air  of  the 
room.  The  latter  possibility  can  only  be  excluded,  unless  compli- 
cated apparatus  and  procedures  are  employed,  by  proving  t]ie  pres- 
ence of  the  fungi  immediately  after  getting  the  stomach-contents — 
i.  e.,  by  microscopic  examination.  The  latter  is,  therefore,  indisjDen- 
sable ;  and,  since  also,  in  the  most  favorable  cases,  it  always  takes  at 
least  twenty-four  hours,  and  usually  longer,  before  the  filtrate  "  ger- 
minates," the  diagnostic  value  of  the  conditions  described  above,  so 
highly  spoken  of  by  Minkowski,  becomes  markedly  diminished  in 
their  essential  features,  although  they  will  always  be  of  pathognostic 
interest. 

At  times  the  vomit  contains  remnants  of  food,  such  as  pits,^ 
fish-scales,  etc.,  Avhich,  as  the  patients  can  prove,  had  been  eaten 
months  before.  Werner  *  found  17  plum  and  920  cherry  pits  in 
a  dilated  stomach,  which  must  have  stayed  there  since  the  previous 
•cherry-season — i.  e.,  fully  three  quarters  of  a  year.  But  at  times 
such  things  remain  in  stomachs  which  are  not  dilated.  Thus,  lately, 
in  the  stomach-contents  obtained  from  a  neurasthenic  I  found  a 
.small  piece  of  fish-skin,  which,  according  to  the  positive  statement 
of  the  patient,  must  have  been  in  the  stomach  for  three  and  a  half 
days. 

The  chemical  relations  of  the  gastric  juice  in  dilatation  of  tlie 

*  "Werner.  Zur  Casuistik  des  Magenkrebses,  etc.  Wiirteraberg.  med.  Corre- 
spondenzbl.  1869,  22-24.  Could  not  the  man  have  eaten  cherry-pie  or  dried  cherries 
in  the  interim  ? 


DECOMPOSITION  OF  STOMACH-CONTENTS.  141 

stomach,  in  so  far  as  this  is  not  dependent  upon  the  presence  of  a 
cancer,  seem  to  be  unchanged  qualitatively.  Should  the  latter  be 
the  cause,  we  will  find  all  the  anomalies  of  secretion  which  will  be 
explicitly  discussed  in  the  lecture  on  carcinoma  of  the  stomach. 
If,  on  the  other  hand,  we  have  to  deal  with  cicatricial  contractions 
of  the  pylorus,  atonic  conditions  of  the  muscle,  hypersecretion,  etc., 
we  find,  almost  without  exception,  either  the  usual  or  increased 
quantities  of  hydrocliloric  acid,  peptone,  and  propeptone,  and  the 
peptic  action  is  satisfactory,  though  usually  somewhat  retarded.  In 
33  cases  Riegel  ^^  found  0*10  to  0'4:6  of  hydrochloric  acid ;  in  20 
cases  which  I  titrated,  the  acidity  due  to  hydrochloric  acid  varied 
between  50  and  80  =  O^IT  to  0-30  per  cent  of  that  acid.  Tlie  pres- 
ence of  hydrochloric  acid  can  be  understood  when  we  recollect  that, 
as  far  as  the  microscopic  picture  permits  us  to  judge,  the  ducts  of 
the  glands  are  for  the  most  part  unchanged,  and  that  the  usual  se- 
cretion of  mucus  in  catarrhal  conditions,  manifestly  due  to  the 
marked  acidity  of  the  stomach-contents,  is  reduced  to  a  minimum, 
and  that  a  so-called  mucous  catarrh  of  the  stomach  does  not  exist. 

However,  this  picture  of  the  normal  condition  of  secretion  is 
complicated  by  the  fermentations  which  take  place  in  the  stomach, 
and  which  cause  secondary  decompositions  of  the  stomach-contents. 
In  another  place  f  I  have  given  the  schema  of  the  fermentation 
of  carbohydrates,  which,  depending  upon  the  abnormal  decomposi- 
tion of  sugar,  appears  at  times  in  the  form  of  the  so-called  oxidation- 
fermentation  (Oxf/dafio?isgdkrtm(jre72),  alcohol,  aldehyde,  and  acetic 
acid  being  formed  from  the  sugar  ;  or  at  other  times  lactic-acid  fer- 
mentation sets  in,  in  which  the  sugar  is  first  decomposed  into  lactic 
acid,  and  later  into  butyric  acid,  carbon  dioxide,  and  hydrogen. 
Both  fermentative  processes  are  due  to  the  presence  of  specific 
organized  ferments,  among  which  we  can  name  yeast,  oidium  lactis, 
and  a  number  of  bacteria,  the  recognition  and  isolation  of  which  are 
to  be  especially  ascribed  to  Iltippe.  Both  processes  may  occur  to- 
gether, and  in  rare  cases  may  be  combined  with  the  products  of 
cellulose  fermentation  ;  though  it  is  questionable  whether  the  latter, 

*  Riegel.    Beitrage  zur  Diagnostik  und  Therapie  der  Magenkrankheiten,     Zeit- 
schr.  f.  klin.  Med.,  Bd.  xi,  Heft  2  u.  8. 

t  Ewald.    Klinik  etc.    I.  Theii,  3.  Auflage,  S.  125, 


142  DISEASES  OF  THE  STOMACH. 

namely,  methane,  and  sometimes  olefiant  gas,  are  derived  from  the 
stomach,  or  whether  they  have  not  rather  regurgitated  from  the 
intestines  into  the  stomach.  The  best-known  case  of  this  kind  is 
that  described  by  Ruppstein  and  myself  j*  of  a  patient  who,  accord- 
ing to  his  own  statement,  "  had  at  times  a  vinegar-factory  and  at 
others  a  gas-factory  in  his  stomach,"  in  whom,  therefore,  the  fer- 
mentation was  sometimes  combined  with  a  predominant  production 
of  acid,  and  at  other  times  caused  a  collection  of  gas.  When  the 
latter  condition  was  present,  he  could  ignite  the  eructated  gases 
through  a  little  roll  of  paper  or  a  cigar-holder,  by  holding  a  lighted 
match  in  front  of  it ;  the  result  was  a  faintly  illuminating  flame. 
In  the  vomit  Ruppstein  demonstrated  the  presence  of  alcohol,  acetic, 
lactic,  and  butyric  acids,  while  I  found  the  gases  to  be  composed  of 
carbon  dioxide,  hydrogen,  methane,  traces  of  olefiant  gas,  oxygen, 
nitrogen,  and  sulphuretted  hydrogen.f  However,  under  the  usual 
circumstances,  it  will  only  be  necessary  for  us  to  demonstrate  the 
presence  of  lactic,  butyric,  and  acetic  acids,  and  in  practice  we  can 
content  ourselves  with  the  proof  of  the  first  two.  It  is  striking 
that  the  total  acidity  of  the  stomach-contents  is  not,  as  a  rule,  ex- 
cessively high,  even  in  cases  of  very  marked  decomposition,  in  spite 
of  the  pungent  odor,  and  in  spite  of  the  complaints  of  the  patients 
concerning  the  acidity  of  the  regurgitated  or  vomited  masses ;  this 
is  evidently  due  to  the  fact  that  when  the  acids  are  formed  they 
become  rapidly  converted  into  neutral  or  basic  salts.  This  is  also 
the  reason  why  the  conversion  of  starch  into  sugar  is  but  slightly 
changed.  Granulose  is  but  seldom  found  ;  we  most  frequently  get 
erythrodextrin  and  large  quantities  of  achroodextrin  or  maltose. 
Another  form  of  abnormal  chemical  change  leads  to  the  prod- 

*  A.  Ewald.  Ueber  Magengahrurag  und  Bildung  von  Magengasen  mit  gelb 
brennender  Flamme.     Reichert's  und  Du  Bois'  Archiv,  1874,  S.  217. 

f  [The  literature  on  this  subject  will  be  found  in  a  paper  by  J.  MeNaught.  A 
Case  of  Dilatation  of  the  Stomach,  accompanied  by  the  Eructation  of  Inflammable 
Gas.  British  Medical  Journal,  1890,  vol.  i,  p.  470.  In  this  case  the  analysis  of  the 
gas  was  as  follows : 

CO2 56"0  per  cent. 

H 280    "      " 

CH4 6-8    "      " 

Residualair 9-2    "      " 

100-0  — Tr.] 


SYMPTOMS  OF  GASTRECTASIS.  I43 

nets  of  decomposition  of  albumen — amido-acids  and  ammonia — 
which  are  characterized  bj  their  pecuHar  foul  odor,  and  under  the 
microscope  by  the  prevalence  of  cocci,  vibriones,  and  masses  of 
zooglea,  some  of  which  may  be  seen  spinning  about  in  the  field  in  a 
lively  manner.  The  reaction  of  the  stomach-contents  is,  then,  usually 
neutral ;  or,  if  the  basic  products  of  the  decomposition  of  albumen 
are  in  excess,  it  may  even  be  faintly  alkaline.  At  any  rate,  because 
there  is  either  an  absence  of  hydrochloric  acid  from  the  commence- 
ment, or  because  it  is  neutralized  by  the  products  of  decomposition 
spoken  of,  an  opportunity  is  given  for  progressive  decompositions 
which  combine  with  the  above-mentioned  processes  of  fermentation, 
and  thus  may  produce  very  varied  clinical  pictures.  As  a  rule  in 
such  cases  we  have  to  deal  with  large  degenerating  neoplasms. 

While  the  stagnation  of  the  stomach-contents  exerts  no  appre- 
ciable influence  upon  the  secretion  of  the  mucous  membrane,  as  long 
as  the  secreting  elements  are  intact,  it  disturbs  absorption  very  seri- 
ously. This  goes  hand  in  hand  with  the  paresis  of  the  motor  ele- 
ments. The  tests  with  iodide  of  potassium  and  with  salol  show  the 
retardation  of  the  absorptive  and  motor  functions.  The  result  of 
the  former  may  be  obtained  from  half  an  hour  to  a  whole  hour  too 
late,  and  I  have  seen  the  latter  absent  as  long  as  two  and  three 
hours.  Nevertheless,  it  is  by  no  means  asserted  that,  in  all  or  in 
particular  cases  of  gastric  dilatation,  these  reactions  are  always  typi- 
cally retarded.  It  must  always  be  borne  in  mind,  however,  that  they 
explain  only  a  function,  and  not  a  group  of  symptoms,  and  that  a 
markedly  dilated  stomach  can  very  well  display  normal  or  nearly 
normal  efficiency  in  this  direction.  But,  under  such  circumstances, 
the  disturbances  which  might  otherwise  develop  tend,  as  a  rule,  to 
be  comparatively  slight.  Thus  in  fourteen  cases  of  typical  dilata- 
tion of  the  stomach,  in  which  I  used  the  salol  test,  I  found  in  five 
that  there  was  no  appreciable  delay  in  the  splitting  up  of  the  salol. 
In  three  of  these  cases,  too,  the  subjective  symptoms  of  dilatation 
of  the  stomach  were  by  no  means  marked,  proving  that  the  ingesta 
were  promptly  passed  on  into  the  intestine,  thus  compensating  for 
the  dilatation. 

It  is  very  apparent  that  these  different  disturbances  of  function 
react  one  upon  the  other.     The  development  of  the  products  of  de- 


144  DISEASES  OF    THE  STOMACH. 

composition  paralyzes  the  muscularis,  and  tliis  paralysis  favors  the 
stagnation  and  with  it  the  further  decomposition  of  the  ingesta. 
The  disturbed  function  of  absorption  not  only  delays  the  removal 
of  absorbable  substances,  but  also  interferes  with  their  further  for- 
mation. In  view  of  the  experiments  of  Schmidt-Miihlheim,  Calm, 
and  others,  we  must  assume  that  the  power  of  the  gastric  juice  to 
form  peptone  ceases  as  soon  as  the  percentage  of  the  latter  has 
reached  a  certain  height,  just  as  alcoholic  fermentation  is  suspended 
as  soon  as  a  definite  quantity  of  alcohol  has  been  formed.  IN^ow, 
since  the  peptones  are  neither  absorbed  nor  transferred  to  the  intes- 
tines at  the  proper  time,  it  follows  that  the  rest  of  the  nitrogenous 
food  is  not  attacked  by  the  gastric  juice ;  and,  hence,  we  find  so 
many  wholly  or  partly  undigested  masses  in  the  stomach  in  spite  of 
the  excessively  long  time  during  which  the  ingesta  remain  in  the 
organ. 

On  the  other  hand,  it  is  evident  that  all  these  conditions  may  be 
present  and  may  manifest  themselves  without  the  existence  of  a 
really  marked  dilatation,  but  rather  of  motor  insufiiciency,  or  what 
the  ancients  called  atony  of  the  stomach.  They  are  then,  it  is  true, 
less  marked,  yet  at  times  they  may  reach  a  high  degree  of  intensity, 
as  the  case  spoken  of  above,  of  the  patient  "  with  the  gas-fac- 
tory," j)roves,  in  whom,  quite  contrary  to  our  assumption  of  a  dila- 
tation of  the  stomach,  based,  it  is  true,  upon  what  we  would  to-day 
consider  insufiicient  examination,  there  existed  an  almost  concentric 
hypertrophy  of  the  stomach  with  a  stenosing  carcinoma  of  the  py- 
lorus.* Such  cases,  therefore,  as  I  have  mentioned  above  must  be 
designated  motor  insufiiciency  of  the  stomach ;  these  will  be  dis- 
cussed more  carefully  when  speaking  of  the  chronic  inflammation 
of  the  gastric  mucous  membrane  and  of  the  neuroses.  From  these 
considerations  we  can  see  that  very  appreciable  dilatations  of  the 
stomach  may  occur,  in  which  the  injurious  effects  are  equalized  by 
efficient  compensation  on  the  part  of  the  absorptive  and  motor  func- 
tions. Thus,  some  individuals  may  for  years  have  an  abnormally 
large  stomach,  which  causes  them  little  or  no  trouble,  just  as  many 

*  A  similar  anatomical  case  was  described  by  Diemerbroeck  in  1685  (and  cited 
by  Penzoldt,  Die  Magenerweiterungen)  in  order  to  prove  that  a  hard  drinker  must 
not  necessarily  have  a  dilatation. 


SYMPTOMS  OF  GASTRECTASIS.  I45 

people  live  for  years  witli  valvular  lesions  in  ignorance  of  tlie  exist- 
ence of  tlieir  trouble,  since  compensatory  liypertropliy  of  the  ven- 
tricle equalizes  tlie  defect  of  the  valve.  But  some  day  this  compen- 
sation fails,  and  then  suddenly,  or  in  a  surprisingly  short  time,  all 
the  symptoms  of  dilatation  appear.  These  are  the  cases  in  which 
the  dilatation  has  apparently  arisen  acutely,  and  which  are  spoken 
of  especially  in  English  literature.*  Thus,  accidentally  from  the 
results  of  the  salol  test,  I  was  able  to  prove  the  existence  of  marked 
gastric  dilatation  by  inflating  the  organ  in  two  old  persons  who  had 
been  in  the  Berliner  Siechenhmts  for  years  without  having  com- 
plained of  any  special  stomach  trouble. 

As  the  disease  progresses  the  nutrition  is  affected  more  and 
more  ;  a  highly  marked  marasmus  appears.  While  vomiting  occurs 
less  frequently,  the  foul-smelling  eructations  and  flatulence  are  in- 
creased. The  pressure  of  the  dilated  stomach  causes  displacements 
of  the  neighboring  organs,  especially  the  lungs,  heart,  liver,  and 
intestines,  together  with  disturbances  of  their  functions.  Dyspnoea 
and  palj)itation  are  increased  according  to  the  extent  to  which  the 
diaphragm  is  forced  upward  by  the  stomach  filled  with  ingesta  or 
distended  by  gases.  Obstructions  to  the  portal  circulation  and  their 
consequences  appear.  The  bowels,  as  a  rule,  are  sluggish,  and  can 
be  moved  only  by  enemata  or  strong  drastics ;  and  the  stools  even 
then  are  usually  not  soft,  but  consist  of  hard  masses  mixed  with 
water  and  mucus.  An  unusual  symptom,  but  when  present  a  very 
conspicuous  one,  is  the  peristaltic  unrest  of  the  stomach,  first  de- 
scribed by  Kussmaul,  to  which  I  have  already  alluded  above  [page 
113],  Powerful  waves  are  seen  passing  slowly  over  the  stomach 
from  I'ight  to  left,  and  from  above  downward ;  they  may  also  affect 
the  lower  sections  of  the  intestines,  and  even  in  rare  cases  take  an 
antiperistaltic  course  (Calm).  ISTaturally,  this  presu]3poses  a  marked 
obstruction  at  the  pylorus  in  connection  with  relatively  intact  muscle 
or  innervation. 

ISTot  only  is  absorption  scanty  or  checked  in  the  stomach,  but  it 
must  also  be  markedly  diminished  in  the  intestine,  which  is  but 

*  For  example,  Hilton  Fagge,  On  Acute  Dilatation  of  the  Stomach,  Guy's  Hosp. 
Reports,  xviii,  pp.  1-23 ;  and  Albutt,  On  Gastrectasis,  Lancet,  1887. 


146  DISEASES  OF  THE  STOMACH. 

insTifficientlj  provided  with  chyme  from  tlie  stomach  at  long  inter- 
vals. This  is  especially  true  of  the  absorj^tion  of  water,  causing  au 
abnormal  dryness  of  the  muscular  and  nervous  tissues  and  of  the 
skin ;  the  latter  is  roughened  almost  like  in  the  last  stages  of  dia- 
betes, and  at  times  thickly  covered  with  furfuraceous  scales.  To 
this  dryness  Kussmaul*  ascribes  a  nervous  phenomenon  observed 
by  him  which  manifested  itself  by  painful  spasms  of  the  flexors  of 
the  arms,  the  calves,  and  the  abdominal  muscles,  with  which  at  times 
a  kind  of  nystagmus,  mydriasis,  emprosthotonos,  as  well  as  disturb- 
ances of  consciousness,  were  associated,  together  with  a  condition 
which  closely  resembled,  if  it  really  was  not,  the  tetany  which  ap- 
pears after  acute  infections,  rheumatism,  conditions  of  great  exhaus- 
tion, etc.  These  attacks  begin  with  painful  sensations  in  the  stom- 
ach and  other  regions  of  the  body,  as  well  as  with  a  feeling  of 
oppression,  and  may  at  times  last  for  many  hours.  Kussmaul  is 
inclined  to  attribute  the  cause  of  these  attacks  to  a  sudden  increase 
in  the  deficiency  of  water  in  the  already  parched  tissues  of  the 
patient  like  those  occurring  in  cholera,  the  sudden  change  being- 
due  to  vomiting  or  lavage.  On  the  other  hand,  we  find  similar 
phenomena  in  other  diseases ;  for  instance,  in  convalescence  from 
typhoid,  and  especially  in  relapsing  fever,  in  which  such  a  factor 
could  not  come  into  consideration.  In  a  case  observed  by  Ger- 
hardt,f  he  calls  attention  to  the  fact  that  the  convulsions  began  in 
the  upper  and  not  in  the  lower  extremities,:]:  as  in  cholera,  and 
ascribes  their  occurrence  to  the  absorption  of  the  products  of  de- 
composition in  the  stagnant  masses  in  the  stomach.  Then,  however, 
they  should  not  have  appeared  during  rational  treatment,  which  is 
exactly  what  took  place  in  Kussmaul's  cases. 

According  to  this  it  seems  that  the  disturbed  absorption  of  water 
and  the  resultant  dryness  of  the  tissues  may  in  individual  cases  be 


*  Kussmaul.  Ueber  die  Behandlung  der  Magenerweiterung,  etc.  Deutsch.  Arch, 
f.  kl.  Med.,  Bd.  vi,  S.  455.  Also  Laprevotte,  Des  accidents  tetaiiiformes  dans  la  dila- 
tation de  I'estomac.     Paris,  1884. 

f  Gerhardt,  quoted  by  Zabludowski.  Zur  Massagetherapie.  Berliner  klin. 
Wochenschr.,  1887,  S.  443. 

\  This  was  also  observed  by  Dujardin-Beaumetz  et  Oettinger:  iNote  sur  un  cas 
de  dilatation  de  I'estomac  continuee  de  tetanic  generalisee.  L'Union  med.,  1884, 
Nos.  15  and  18. 


TETANY.  147 

tlie  cause  of  an  abnormal  irritability  of  the  nervons  system  wliicli 
may  become  intensified  sufficiently  to  present  the  picture  of  tetany ; 
in  other  cases,  however,  owing  to  the  absorption  into  the  blood  of  the 
products  of  decomposition,  there  may  appear  an  auto-infection  char- 
acterized by  nervous  depression,  which  has  been  aptly  named  "  coma 
dyspepticumr  Fr.  Miiller  *  has  reported  two  cases  of  the  former 
kind  in  which,  in  addition  to  the  symptoms  already  mentioned, 
there  was  a  distinct  increase  in  the  mechanical  and  electrical  excita- 
bility of  nerve  and  muscle  ;  Minkowski  f  mentions  the  occurrence 
of  deep  coma  in  the  course  of  a  case  of  dilatation  of  the  stomach, 
the  patient  dying  in  this  state  two  days  later  ;  while  Litten  observed 
similar  though  not  such  intense  conditions  in  cases  of  acutely  de- 
veloped dyspepsia,  and  obtained  the  ethyl-diacetic-acid  reaction 
[Gerhardt's  Burgundy-red  reaction]  in  the  urine.  :j:  This  seems  to 
point  to  the  formation  and  absorption  of  substances  wdiich  are 
normally  not  present  in  the  gastro-intestinal  tract,  or,  at  any  rate, 
not  normally  absorbable  ;  yet  from  the  stomach-contents  of  his  cases 
of  tetany  Fr.  Miiller  failed  to  isolate  a  poisonous  alkaloid  or  toxin, 
perhaps,  as  he  himself  says,  because  the  masses  examined,  although 
they  had  an  unpleasantly  sour  odor,  did  not  have  the  typical  odor 
of  decay  and  no  very  marked  decomposition  had  taken  place. 
Finally,  therefore,  the  possibility  remains  that  this  form  of  tetany 
represents  a  reflex  process  proceeding  from  the  stomach,  and  for 
which  many  analogies,  collected  by  Miiller,  could  be  found,  of 
which  I  will  only  mention  the  convulsions  caused  by  worms.  Tet- 
any is  always  a  severe  complication  of  gastric  dilatation,  for,  of 
the  eight  cases  collected  by  the  author  just  mentioned,  five  w^ere 
fatal,  a  mortality  of  62"5  per  cent.* 

As  long  as  the  disease  pursues  its  course  undisturbed,  the  urine 
in  dilatation  of  the  stomach  manifests  no  special  changes.     I  have 


*  Pr.  Mailer.  Tetanie  bei  Dilatatio  ventriculi  und  Achsendrehung  des  Magens. 
Charite-Annalen,  1888,  Bd.  xiii,  S.  273. 

f  Minkowski,  loc.  cit.,  p.  168. 

X  M.  Litten.  Eigenartiger  Symptomeneomplex  in  Folge  von  Selbstinfection  bei 
dyspeptisehen  Zustanden.    Zeitschr.  f .  klin.  Med.,  Bd.  vii.   Supplementheft,  S.  81  u.  ff. 

*  [See  also  M.  Loeb.  Tetany  from  Gastric  Dilatation  from  Pyloric  Cancer.  Jour- 
nal of  Nervous  and  Mental  Diseases,  New  York,  November,  1890 ;  Martin,  La  Loire 
medieale,  November  15,  1890. — Tr.] 


148  DISEASES  OP  THE  STOMACH. 

never  observed  the  peptonuria  spoken  of  by  G.  See  and  found  by 
Bouchard  in  7  per  cent  of  his  cases,  although  I  have  examined 
many  patients  for  that  purpose.  At  times,  in  the  later  stages  of 
the  disease,  the  quantity  of  the  urine  is  diminished,  though  this  is 
not  usual.  Perhaps  this,  like  the  alkalinity  of  the  urine,  which 
may  be  observed  under  certain  circumstances,*  is  to  be  referred  to 
the  reo-ular  emptying  or  washing  of  the  stomach  undertaken  in  the 
course  of  treatment.  Quincke  believes  the  cause  to  be  the  deficient 
absorption  of  the  acid  of  the  stomach  by  the  gastric  mucosa,  where- 
by an  important  factor  in  the  acidifying  of  the  urine  is  removed. 
This  is  quite  possible  so  long  as  the  changes  in  the  chemical  func- 
tions connected  with  dilatation  are  not  remedied.  On  the  contrary, 
it  seems  to  me  that  the  greater  the  care  which  is  taken  to  improve 
the  organ  by  systematic  lavage,  the  more  favorable  must  the  con- 
ditions of  absorption  become,  and  that  therefore  the  urine  should 
be  acid  rather  than  alkaline.  This  is  also  corroborated  by  an  ob- 
servation of  Winkhaus,t  who  collected  the  urine  in  separate  portions 
at  various  periods  dm-ing  the  day  in  a  patient  with  a  marked  gas- 
trectasis  ;  the  urine  was  alkaline  as  long  as  the  fermentation  in  the 
stomach  w^as  not  interfered  with,  but  invariably  became  acid  some 
time  after  the  stomach  was  washed  out.  Moreover,  it  depends  en- 
tirely on  the  actual  cause  of  the  dilatation  whether  any  quantities 
of  hydrochloric  acid  worth  mentioning  are  secreted  by  the  stomach. 
Diagnosis. — Were  I  to  follow  the  usual  plan  and  now  take  up 
the  diagnosis  of  dilatation  of  the  stomach,  I  would  simply  have  to 
repeat  what  has  already  been  said,  for  whatever  has  reference  to  the 
diagnosis  has  already  been  fully  discussed  ;  it  is  just  in  dilatation  of 
the  stomach  that  the  differential  diagnos^'s  is  relegated  more  than 
elsewhere  to  the  background.  It  is  apparent  that  we  must  guard 
against  confounding  this  condition  with  distention  of  the  colon, 
ovarian  cysts,  sacculated  ascites,  hydronephrosis,  and  echinococcus 
cysts ;  however,  on  careful  examination  by  the  methods  given,  these 
can  hardly  claim  our  earnest  attention.     On  the  whole,  the  tend- 

*  Quincke.  Dilatatio  ventriculi  mit  Durchbruch  in  das  Colon.  Eigenthilm- 
liches  Verbal  ten  des  Urins.     Correspondenzbl.  fur  Schweizer  Aerzte.  1874.  No.  1. 

f  H.  Winkhaus.  Beitrag  zur  Lehre  von  der  Magenerweiterung.  Inaug.  Diss. 
Marburg,  1887. 


COURSE  AND   PROGNOSIS  OF  GASTRECTASIS.  149 

ency  of  physicians  is  to  make  tlie  diagnosis  of  "  dilatation  of  tlie 
stomach"  ratlier  too  often  than  too  seldom,  except,  as  I  have 
already  mentioned,  when  it  occurs  in  young  persons.  It  would  be 
of  very  great  importance  were  we  able  to  sharply  distinguish  be- 
tween insufSciency  of  the  stomach  and  true  gastectrasis.  This  is 
easy  as  long  as  we  have  to  deal  with  the  group  of  symptoms  of  a 
dilatation  when  no  truly  dilated  stomach  is  present — under  such 
circumstances  it  may  be  extremely  difficult  to  exclude  a  primary 
catarrhal  condition — yet  it  is  impossible,  and  the  diagnosis  can  only 
be  made  ex  jicva/titihus  when,  with  a  relatively  short  duration  of  the 
disease  and  poorly  marked  symptoms,  a  megastria  exists  at  the 
same  time,  and  thus  simulates  an  incipient  gastrectasis.  In  advanced 
cases  we  can  not  remain  in  doubt,  even  under  such  circumstances. 

Course  and  Prognosis. — Both  are  intimately  connected  with  the 
primary  cause  of  the  gastric  dilatation.  If  it  be  due  to  a  malignant 
tumor,  the  duration  of  life  is  dependent  upon  the  course  of  the  can- 
cerous disease  and  the  prognosis  is  always  unfavorable  ;  yet  we  must 
not  forget  that  remissions  may  occur  in  the  course  of  such  processes 
which  under  the  influence  of  rational  treatment  may  produce  a  rela- 
tively good  condition  for  weeks,  and  even  for  months.  It  is  to  this 
fact  that  the  majority  of  the  cases  reported  "  cured "  can  probably 
be  referred.  I,  at  least,  have  never  seen  such  a  gastric  dilatation 
cured,  but  I  have  repeatedly  observed  that  such  periods  of  improve- 
ment threw  doubt  upon  the  diagnosis  till  it  was  finally  confirmed  at 
the  autopsy. 

When  the  dilatations  are  caused  by  constricting  cicatrices,  or  by 
atonic  conditions  of  the  gastric  muscle,  they  run  a  slower  course, 
and  the  prognosis  is  on  the  whole  more  favorable.  But  here,  too, 
alas !  we  must  say,  "  PrcBVCtlahunt  fata  consiliis  !  "  Such  patients 
carry  their  dilated  stomachs  about  with  them  for  years,  and  under 
appropriate  treatment  and  diet  can  lead  an  endurable  life — indeed, 
one  almost  free  from  all  difficulties ;  but  they  never  dare  forget  that 
every  "  step  from  the  path" — i.  e.,  every  dietetic  error — which  need 
by  no  means  be  gross,  but  simply  a  very  slight  departure  from  the 
prescribed  diet,  entails  not  only  a  momentary  feeling  of  sickness 
but  usually  severe  disturbances,  which  sometimes  can  not  be  relieved 
at  all ;  for  it  is  a  peculiar  characteristic  of  all  dyspeptic  conditions 


150  DISEASES   OP  THE   STOMACH. 

of  a  severe  and  chronic  nature  that  thej  not  only  may  relapse 
easily,  but  that  these  relapses  last  longer  and  are  worse  than  the  first 
attack.  But  it  must  be  specially  emphasized  that  the  treatment  of 
dilatations  of  the  stomach  when  they  are  recognized  early  offers  us 
a  very  grateful  field  for  treatment,  unless,  which  is  not  unusually 
the  case,  they  have  been  treated  in  the  mean  time  with  all  manner  of 
purposeless  "  stomach  medicines."  We  can  very  safely  promise  such 
patients  a  very  marked  improvement  in  their  trouble  ;  in  fact,  were 
we  only  to  regard  the  subjective  symptoms,  we  could  promise  a 
cure.  But,  if  we  did,  such  a  falsehood  would  be  punished  in  the 
future.  As  far  as  my  experience  goes,  even  these  dilatations  can 
not  be  cured,  and  the  final  prognosis  is  always  unfavorable  ;  at 
least,  in  four  cases  which  I  have  had  the  opportunity  of  watching 
for  years — over  six  and  as  long  as  eight  years — I  have  found  the 
stomach  just  as  large  as  ever  when  I  distended  it,  in  spite  of  sub- 
jective improvements  and  even  apparent  cure ;  the  result  has  been 
just  the  same  in  the  many  cases  of  dilatation  of  the  stomach  of  this 
category  which  I  have  had  the  opportunity  of  observing  for  shorter 
periods  of  time.  "When  the  stomach  is  once  dilated  Ave  are  unable 
to  draw  it  together  again  like  a  tobacco-pouch,  any  more  than  an 
eccentrically  hypertrophied  heart  (excepting  the  isolated  cases  of 
acute  cardiac  dilatation)  ever  returns  to  its  normal  condition.  As 
soon  as  the  muscular  and  glandular  tissues  have  been  forced  apart 
and  infiltrated  by  an  abundant  proliferation  of  interstitial  tissue ; 
as  soon  as  the  muscular  fibers  have  undergone  fatty  or  other  degen- 
erations ;  as  soon  as  the  ducts  of  the  glands  have  been  destroyed  or 
have  undergone  cystic  degeneration — in  short,  as  soon  as  atonic 
atrophy  of  the  walls  of  the  stomach  has  appeared,  the  game  is  lost. 
Gradually  our  therapeutic  and  dietetic  measures  lose  their  efficacy, 
and  the  patients  die  of  marasmus,  and  with  more  or  less  marked 
dropsical  effusions. 

We  can  only  expect  a  decided  improvement,  or  even  a  cure  of 
the  gastric  dilatation,  when  the  process  is  in  its  earliest  stages  and 
is  produced  by  functional  disturbances,  atony,  deficient  innervation, 
or  catarrhal  conditions  of  the  mucous  membrane,  or  when  the  ob- 
struction to  the  emptying  of  the  stomach  is  immediately  removed 
by  operative  procedures,  as  in  the  above-mentioned  case  of  Klem- 


TREATMENT   OP   GASTEECTASIS.  151 

perer.  Here  the  relaxed  muscle  may  regain  its  tone  and  the  mu- 
cous membrane  its  normal  structure  and  function,  the  interstitial 
exudation  may  be  absorbed,  and  the  organ  in  toto  brought  back  to 
its  original  size.  It  is  very  evident  that  all  this  is  only  possible  pro- 
vided the  anatomical  changes  have  not  exceeded  a  definite  and  very 
limited  degree ;  this  is  quite  analogous  to  the  conditions  of  other 
organs — the  bladder,  for  instance. 

Those  cases  of  dilatation  of  the  stomach  which  arise  from  a  chlo- 
rotic  or  anaemic  condition,  and  which  have  been  described  as  cured, 
can  not  be  classed  with  the  true  dilatations,  as  I  have  defined  them 
above,  but  belong  to  the  group  of  gastric  insufiiciency,  which  may 
at  times  be  combined  with  a  megastria. 

The  treatment*  of  dilatation  of  the  stomach  must  fulfill  two 
indications  :  1.  By  means  of  a  carefully  selected  diet,  and  appro- 
priate medication,  it  must  ease  and  assist  gastric  digestion  as  much 
as  possible,  and  even  supply  nutriment  to  the  organism  in  another 
way.  2.  It  must  prevent  stagnation  of  the  stomach-contents  and 
must  expel  them  either  upward  or  downward,  and  must  also  check 
the  fermentative  processes  which  develop  in  the  stomach. 

The  quantity  of  food  in  dilatation  of  the  stomach  should  be  as 
limited  as  possible.  "We  must  restrict  the  use  of  fluids  as  far  as  we 
can ;  thin  soups,  large  quantities  of  alcoholic  beverages,  mineral  or 
other  waters,  and  much  tea  or  coffee,  are  to  be  entirely  avoided.  I 
make  use  of  milk  even  in  only  small  quantities,  and  give  it  in  tea- 
spoonful  or  tablespoonful  doses  at  frequent  intervals.  Under  such 
circumstances  the  most  rational  course  to  pursue,  if  possible,  would 
be  to  use  Schroth's  dry  diet  {Trochenhur).\  But  since  the  treatment 
must  extend  not  over  short  periods  of  time,  but  over  months,  and 
even  years,  this  is  not  applicable,  and  we  must  therefore  satisfy 
ourselves  with  a  modified  dry  diet.  Germain  See,  strange  to  say, 
considers  the  withdrawal  of  fluids  unnecessary,  since,  he  thinks, 

*  [See  also  yaluable  paper  by  Oser,  Wiener  med.  Presse,  Sept.  25,  1889. — Tr.] 
f  [This  very  energetic  treatment,  as  modified  by  JQrgensen,  consists  in  giving 
the  patient  as  many  dry  rolls  as  he  wishes^  and  also  a  third  to  two  thirds  of  a  pound 
of  lean  meat  and  a  pint  of  light  claret  wine ;  no  other  fluids  are  allowed,  except  on 
every  third  or  fourth  day,  when  drinking  is  permitted.  Wet  packs  at  night.  Before 
the  cure,  fluids  are  gradually  withdrawn,  and  after  it  they  are  gradually  increased. 
The  treatment  lasts  about  a  month.— Schlesinger,  Hulfsbiichlein,  etc.,  S.  45. — Tr.] 


X52  DISEASES  OF  THE   STOMACH. 

they  are  absorbed  tlie  most  rapidly  and  easily.  This  is  a  fatal  error, 
for  there  is  also  a  delay  in  the  absorption  of  fluids ;  they  remain  in 
the  stomach,  and  not  only  do  they  favor  fermentation,  but  throngh 
their  weight  also  mechanically  dilate  the  organ.  The  nse  of  the 
peptone  preparations  is  to  be  recommended  ;  for  instance.  Koch's 
or  Kemmerich's  meat  peptones,  meat  peptone  chocolate,  Maggi's 
peptone  pastilles,  [Valentine's]  meat-juice,  etc.,  'vrhich  contain  much 
nourishment  in  a  small  volume.*  I  have  lately  found  condensed 
peptonized  milk  to  be  very  serviceable ;  it  has  an  agreeable  taste, 
and  can  be  purchased  in  small  packages  as  the  so-called  ''  Miitter- 
railchjpatronen^''  or  of  a  gelatinous  consistency  in  larger  boxes.  The 
patients  also  like  meat-powder,f  which  can  easily  be  made  at  home 
from  dried  and  pulverized  meat ;  it  is  made  into  a  broth,  with  the 
addition  of  spices.  It  is  evident  that  all  easily  fennenting  food- 
stuffs, especially  amylaceous  foods  and  the  vegetables  and  fi'uits 
which  contain  much  sugar,  are  to  be  absolutely  avoided ;  and  it  is 
only  as  a  concession  to  the  imperative  necessity  for  starchy  foods 
that  we  permit  the  patients  to  have  a  smaE  quantity  of  bread,  say 
T5  to  100  grammes  [  §  ijss-  to  iijss.]  daily — i.  e.,  two  or  three  rolls. 
The  decomposition  of  the  fats  evidently  takes  place  late  and  slowly, 
for  in  washing  out  the  stojnach  six  to  seven  houi"s  after  a  meal  we 
find  the  fat  floating  in  large  and  small  globules  on  the  surface  of 
the  water,  and  no  intense  odor  of  the  fatty  acids  is  noticeable,  which 
is  always  the  case  unless  the  stomach  is  systematically  washed  out. 
However,  since  the  fats  seem  to  exert  an  irritant  action  on  the 
mucous  membrane,  their  use  is  to  be  restricted  as  much  as  possible. 
The  strength  of  the  patient  may  be  kept  up  by  means  of  small 
quantities  of  strong  wine  or  strong,  unsweetened  cofiee  or  tea.  Nu- 
trient enemata  form  an  important  aid  in  nourishment ;  they  may  be 
given  in  the  form  which  I  have  spoken  of,  or  as  suppositories  of 
peptone,  the  use  of  which  can  be  continued  for  weeks  or  months. 
By  such  means  nourishment  by  the  mouth  may  be  reduced  to  a 
minimum  for  days — i.  e.,  until  the  condition  of  gastric  digestion  has 
been  improved  as  much  as  possil^le ;  enemata  also  possess  the  ad- 

*  [Analogous  preparations  are  Rudiseh's  sarcopeptones,  Camriek's  beef  pepto- 
noids,  Bush's  bovinine,  etc. — Tr.] 

"t-  [Parke,  Davis  &  Co.'s  Mosquera's  Beef-Meal  may  be  used  for  this  purpose. — Tk.] 


TREATMENT   OF   GASTRECTASIS.  153 

vantage  of  preventing  the  lack  of  water  in  the  tissues  by  means  of 
the  fluids  introduced  (Liehermeister). 

Hydrochloric  acid  in  large  doses  is  an  excellent  remedy  for  all 
.gastric  dilatations  which  are  not  dependent  upon  pure  atony  of  the 
muscle.  TTe  may  commence  with  ten  to  fifteen  drops  of  dilute 
hydrochloric  acid,  taken  through  a  glass  tube  in  a  tablespoonful  of 
water  every  hour.  Salicylic  acid  pm-e,  or  in  the  form  of  sahcylate 
of  bismuth,  in  doses  of  0-3  to  O'S  gramme  [gr.  ivss.  to  vijss.],  as  well 
as  benzin,  are  to  be  recommended.  Minkowski  recommends  the  use 
of  carbolic  acid  in  large  doses — O'l  [tU  jss.]  !  and  over — to  be  taken 
in  pills  before  meals.  I  have  seen  good  results  from  the  use  of 
creasote,  which  was  given  by  Mannkopff  as  early  as  1861,  in  cases 
of  gastric  fermentation,  in  doses  of  0*1  to  0-2  [^^,  jss.  to  iij]  several 
times  daily.  If  carcinoma  of  the  stomach  exists,  it  is  best  to  use  a 
maceration  of  condurango,  with  the  proper  quantity  of  hydrochloric 
acid.  In  ease  there  is  much  pain  in  the  stomach,  I  make  use  of 
the  sedative  and  antiseptic  action  of  cliloral,  combined  Avith  cocaine, 
as  follows : 

5:   Cocain.  hydrochlor 0"3  [gr.  jvss] 

Chloral  hydrat 3'0  [gr.  xlv] 

Aq.  menth.  pip 50-0  [f  3  jf  ] 

Aq 100-0  [ffiiji] 

M.  Sig. :  Tablespoonful,  p.  r.  n. 
Dujardin-Beaumetz  speaks  highly  of  introducing  large  doses 
of  bismuth,  50  grammes,  suspended  in  500  c.  c.  of  water  [  §  jss.  bis- 
muth to  O  j  water],  from  which  the  drug  is  said  to  be  deposited  on 
the  gastric  mucous  membrane ;  *  injections  of  morphine  are  eventu- 
ally unavoidable.  Atonic  conditions  of  the  muscle  require  the  exhibi- 
tion of  strychnine,  as  extract  or  tincture  of  nux  vomica,  wliich  had 
been  formerly  recommended  by  Skjelderup  and  Duplay.f  who  did 
not  draw  this  sharp  distinction.  It  can  be  given  without  bad  effects 
in  large  doses — O'l  to  0*15  [gr.  jss-iji]  I  of  the  extract  pro  die.  Dr. 
AYolfE  has  proved  at  my  clinic  that  it  also  increases  the  production 
of  hvdrochloric  acid. 


*  Bullet,  gener.  de  therapeutiqne,  1883,  Xo.  1. 

f  Arch,  gener.  de  med.,  1883,  Xov.,  Dec. 


154  DISEASES   OF   THE   STOMACH. 

The  cathartics  and  drastics  have  always  played  an  important 
part  in  the  therapy  of  gastric  dilatation  ;  they  are  really  of  service, 
probably  by  syijipathetic  stimulation  of  the  gastric  peristalsis,  not 
only  in  evacuating  the  intestines  but  the  stomach  as  well,  as  soon 
as  they  have  passed  the  pylorus,  or,  indeed,  have  been  absorbed  at 
all,  neither  of  which  is  always  the  case.  Penzoldt  was  able  to 
directly  prove  the  beneficial  effect  of  Carlsbad  salts  in  lessening  the 
quantity  of  the  stomach-contents,  for  the  quantity  removed  from 
the  organ  while  the  salts  were  used  amounted  to  850  c.  c.  [f  ^  xxviij], 
while  without  them,  the  condition  being  otherwise  the  same,  they 
measured  1,525  c.  c.  [3|-  pints].  Kussmaul  recommends  drastic  pills, 
composed  of  1^  Extr.  colocjmth.  spirit.  (G.  P.),  0*5  [gr.  vijss.] ; 
extr.  rhei  comp.  (G.  P.)  sive  extr.  aloes  aquos.,  scammonii,  aa  2*0 
[gr.  xxx].  M.  Ft.  pil.  no.  xxx.  Sig. :  Before  dinner.  I  have 
frequently  used  aloin  subcutaneously  with  good  results. 

To  meet  the  second  of  the  two  indications  given  above,  lavage, 
the  sovereign  remedy  in  the  treatment  of  dilatation,  is  to  be  used. 
I  will  disregard  the  many  appliances  devised  for  this  purpose, 
because,  to  my  mind,  they  are  like  carrying  coals  to  ]^ewcastle. 
The  use  of  the  stomach-tube,  with  a  funnel  attached  to  it,  and  the 
cleansing  of  the  stomach  by  the  alternate  introduction  and  removal 
of  large  quantities  of  water,  is  the  simplest  and  at  the  same  time 
an  entirely  efficient  method.  We  must  not  stop  until  the  water 
returns  clear  or  only  very  slightly  turbid,  but  by  all  means  entirely 
free  from  fragments  of  food  and  flakes  of  mucus.  At  times, 
toward  the  end  of  the  operation,  after  the  water  has  come  back  clear 
for  some  time,  it  suddenly  becomes  turbid  again  from  the  presence 
of  large  masses  of  stomach-contents ;  this  occurs  especially  when 
there  are  well-marked  pouches  in  the  stomach,  the  contents  of  which 
are  only  stirred  up  toward  the  last  by  the  entrance  of  the  water  or 
the  bearing  down  of  the  patient.  We  must  allow  all  the  time  we 
can  for  the  possible  digestion  of  the  food  which  may  be  in  the 
stomach,  and  therefore  we  must  only  empty  the  stomach  when  large 
accumulations  are  present — i.  e.,  to  wash  out  only  six  or  seven 
hours  after  the  principal  meal.  Besides  the  actual  washing  out 
which  is  to  prevent  the  mechanical  overloading  of  the  stomach,  we 
conclude  the  operation  with  irrigation  of  the  mucous  membrane 


LAVAGE  IN  DILATATION.  155 

with  antiseptic  or  antifermentative  solutions.  In  cases  of  very 
marked  fermentation  we  can  clean  the  walls  of  the  stomach  more 
qnicklj  and  thoroughly  by  washing  out  the  stomach  in  the  morn- 
ing before  breakfast  when  the  viscus  is  empty,  as  Naunyn  and 
Minkowski  have  also  advised.  I  have  had  patients  in  whom  the 
morning  lavage  produced  much  better  results  than  that  done  in  the 
evening.  As  antiseptics  we  may  use  solutions  of  salicylic  acid  0*3 
to  0'5  per  cent,  or  borax  2  to  4  per  cent  (dissolved  in  hot  water),  or 
sodium  subsulphate  10  to  20  per  cent,  as  well  as  a  great  number  of 
other  disinfectants,  such  as  naphthalin,  resorcin,  benzoic  acid,  per- 
manganate of  potash,  etc.  These  substances,  the  efficacy  of  which 
is  well  known,  should  suffice. 

The  advantages  which  accrue  from  this  procedure  are  so  appar- 
ent that  it  is  really  incomprehensible  why  this  method  should  not 
have  been  introduced  earlier  into  therapeutics.  To  avoid  repetitions 
I  shall  not  add  anything  further  on  the  benefits  of  lavage  of  the 
stomach,  for  its  manifold  advantages  can  readily  be  recognized. 
However,  of  one  of  these  I  must  speak,  for  it  appears  very  fre- 
quently, if  not  always — namely,  the  effect  on  the  stools.  Many 
patients  who  have  had  to  contend  with  habitual  constipation 
throughout  the  whole  course  of  their  illness  have  had  free  pas- 
sages after  the  washings,  especially  at  the  commencement  of  the 
treatment.  Kussmaul,*  who  has  called  attention  to  this  effect  of 
lavage,  always  considers  its  absence  an  ominous  sign ;  in  other 
words,  he  believes  that  the  persistence  of  obstinate  constipation 
always  indicates  an  irreparable  disorganization  of  the  stomach  and 
an  incurable  stenosis  of  the  pylorus.  But  this  much  is  certain^ 
that  in  scarcely  any  other  place  in  the  whole  range  of  the  therai^y 
of  diseases  of  the  stomach  can  we  attain  such  l)rilliant  results  as 
we  can  in  the  treatment  of  a  case  of  protracted  dilatation  of  the 
stomach.  The  disgusting  vomiting,  the  feeling  of  fullness,  the 
eructations,  the  dyspeptic  difficulties,  and  the  cerebral  symptoms 
either  cease  entirely  or  become  markedly  improved.  Unfortunately, 
in  true  dilatations,  as  I  have  stated  above,  these  results  are  merely 
palliative. 


*  Loc.  cit.,  p.  467. 


156  DISEASES  OF  THE  STOMACH. 

How  often  sliall  we  wasli  out  the  stomach  ?  Daily,  or  at  longer 
intervals,  or  as  often  as  several  times  a  day  ?  I  consider  daily  wash- 
ings at  the  time  specified  to  be  indispensable  and  also  sufficient. 
But  they  must  be  conscientiously  continued  for  a  long  time — the 
patients  soon  learn  to  do  it  themselves — and  we  must  not  be  guided 
alone  by  the  subjective  sensations  of  the  patient.  Should  the  lat- 
ter's  apparently  good  condition  induce  us  to  allow  longer  intervals 
to  intervene,  so-called  relapses  are  sure  to  occur,  since  stagnation 
and  its  consequences  will  always  return.  The  present  technique  is 
so  simple  and  safe  that  less  can  be  said  against  it  than,  for  instance, 
against  long-continued  catheterization  in  hypertrophy  of  the  pros- 
tate. I  have  as  yet  never  seen  any  unpleasant  accidents  occurring 
after  lavage,  yet  we  find  a  case  reported  by  Martin  *  in  which  death 
suddenly  occurred  six  hours  after  a  tube  had  been  introduced  into  a 
dilated  stomach  with  stricture  of  the  pylorus.  No  injury  of  the 
viscus  was  found  at  the  autopsy,  and,  since  sudden  collapse  and 
death  may  occasionally  occur  in  cases  of  cancer  without  any  cause 
at  all,  it  appears  to  me  that  this  was  simply  a  coincidence. 

Massage  and  faradization  of  the  stomacli  I  consider  adjuvants 
of  lavage.  The  former,  if  intellige^ntly  applied,  forces  the  contents 
of  the  stomach  into  the  intestines,  and  in  this  way  dilates  the  py- 
lorus by  means  of  mechanical  pressure.  Yet  we  must  avoid  forcing 
masses  into  the  duodenum  which  are  too  acid  or  too  acrid,  which 
can  not  be  sufficiently  neutralized  by  the  intestinal  juices,  and  which 
produce  conditions  of  irritation  in  the  mucous  membrane  of  the 
intestine.  Zabludowski,f  of  Gerhardt's  clinic,  has  published  very 
good  results  from  the  use  of  massage  in  dilatation  of  the  stomacli, 
together  with  an  exact  account  of  the  technique  employed. 

Up  to  the  present  time  it  has  been  difficult  to  say  whether  fara- 
dization of  the  abdominal  walls  had  any  effect  upon  the  gastric 
muscle,  and  whether  it  was  not  rather  entirely  limited  to  the  con- 
traction of  the  abdominal  muscles.  Pepper,:|:  in  a  case  of  dilatation 
due  to  cancer  of  the  pylorus  with  plainly  visible  peristalsis,  was 

*  Martin.    Death  after  washing  out  Dilated  Stomach.    Lancet,  1887,  No.  3. 
f  Zabliidowski.     Zur  Massagetherapie.     Berliner  klin.  Wochenschrift,  1886,  S, 
443. 

X  Pepper.    A  Case  of  Scirrhus  of  the  Pylorus,  etc.    Phila.  Med.  Times,  Mav,  1871. 


SURGICAL  PEOCEDURES.  157 

unable  to  stimulate  tlie  latter  by  either  tlie  faradic  or  galvanic  cur- 
rents. However,  it  lias  been  shown  by  the  experiments  made  with 
the  salol  test  by  Dr.  Sievers  and  myself,  and  also  by  Einhorn,  that 
the  passage  of  the  stomach-contents  into  the  intestine  is  really  hast- 
ened by  energetic  external  faradization  in  the  region  of  the  stom- 
ach. Brunner  *  obtained  the  same  result,  for  he  observed  that  the 
test-breakfast  disappeared  much  more  rapidly  than  usual  from  the 
stomach  when  the  abdominal  walls  were  energetically  faradized, 
although,  it  is  true,  the  salol  test  left  him  in  the  lurch.  The  effect 
would  be  more  certain  if  we  applied  the  electrodes  locally,  intro- 
ducing one  into  the  stomach  and  placing  the  other  upon  the  ab- 
dominal walls  or  in  the  rectum,  so  as  to  include  the  entire  diges- 
tive tract  in  the  current,  and  thus  to  obtain  very  powerful  action. 
[See  page  66.1  Cold  douches  and  applications  are  said  to  have 
a  tonic  effect  upon  the  muscle-fibers  of  the  stomach,  as  well  as 
the  so-called  Scotch  douche,  as  recommended  by  Winternitz  and 
Baum.f 

Finally,  we  must  think  of  dilatation  or  excision  of  tlie  stenosis. 
I  can  do  no  more  than  mention  these  procedures  here,  and  therefore 
simply  call  your  attention  to  the  fact  that  quite  a  series  of  success- 
ful operations,  either  excision  of  the  constricting  tumor  or  forcible 
dilatation  of  cicatricial  stenosis,  has  been  published  during  the  past 
few  years.  Thus,  Hubert  describes  two  cases  of  forcible  digital 
dilatation  of  cicatricial  stenosis  of  the  pylorus  which  were  operated 
upon  by  Prof.  Loreta  in  Bologna,  and  apparently  were  radically 
cured.:}:  A  method  which  may  be  worthy  of  special  consideration  is 
that  proposed  by  Heinecke  and  Mikulicz,  of  splitting  the  stricture 
longitudinally  and  then  passing  the  sutures  transversely  ;  a  number 

*  W.  Brunner.  Zur  Diagnostik  der  motorisehen  Insuffieienz  des  Magens. 
Deutsche  med.  Wochensehr.,  1889,  No.  7. 

f  Wiener  med.  Presse,  1873,  No.  17.  ["This  consists  of  a  stream  of  water,  the 
size  of  a  finger,  whic  his  directed  against  the  region  of  the  stomach.  The  tempera- 
ture of  the  water  changes  every  twenty  seconds  between  80°  and  50°  Fahr.  (26°  and 
10°  C),  and  is  continued  for  three  minutes."  Decker,  Miinch.  med.  Wochen.,  May 
28,  1889.     Reviewed  in  Annual  of  Univers.  Med.  Sc,  1890,  vol.  i,  C.  p.  9.— Tr.] 

X  Hubert.  Deux  cas,  etc.  Jour,  de  med.  de  Bruxelles,  Avril,  1883,  pp.  309  to 
318.  [Also  Loreta,  Lancet,  April  26,  1884;  Bull  and  Kinnicutt,  "A  Case  of  Cica- 
trical Stenosis  of  Pylorus  relieved  by  Loreta's  Operation."  New  York  Medical  Rec- 
ord, June  8,  1889.     This  paper  gives  results  of  twenty  eases. — Tr.] 


158  DISEASES  OP   THE   STOMACH. 

of  good  results  have  lately  been  obtained  by  this  method.*  How- 
ever, I  must  leave  this  field  to  the  surgeons,  to  whom  the  clinician  can 
only  refer  suitable  cases  with,  as  exact  a  diagnosis  and  prognosis  cs 
possible.  The  results  of  my  personal  observations  on  this  subject 
lead  me  to  believe  that  operative  gastric  surgery  has  a  great  future 
before  it,  and  perchance  the  time  is  not  far  distant  when  we  will 
excise  a  lancet  or  leaf  shaped  piece  from  a  dilated  stomach  in  the 
same  way  that  we  treat  prolapse  of  the  vaginal  mucous  membrane 
and  of  the  uterus  by  wedge-shaped  excision.f  How  our  views  and 
hopes  have  changed  since  the  time  when  Kussmaul,:};  as  recently  as 
1869,  feared  "  that  he  would  meet  with  quiet  or  outspoken  scorn  " 
by  the  mere  mention  of  such  possibilities ! 

I  shall  now  apply  the  foregoing  remarks  to  some  practical  ex- 
amples ;  for  this  purpose  I  liave  not  selected  hospital  cases,  with  the 
results  of  autopsies,  but  such  patients  as  we  meet  in  daily  practice : 

The  first  patient  is  a  railroad  secretary,  fifty-two  years  of  age,  whose 
previous  history  I  shall  read  to  you  in  his  own  words : 

"  Ten  months  ago,  in  the  beginning  of  last  year,  I  was  taken  sick  with 
loss  of  appetite,  constipation,  slight  malaise^  and  also  a  cough,  with  expec- 
toration. On  the  14th  of  June,  a  ye$,r  ago,  I  went  to  Gorbersdorf,  in 
Silesia,  at  the  advice  of  my  physician,  and  remained  there  under  treat- 
ment, at  the  institute  of  Dr.  Eompler,  until  July  10th.  On  July  10th  I 
went  to  Carlsbad,  where  the  diagnosis  of  dilatation  of  the  stomach  was 
made.  I  w^as  treated  there  till  August  14th  (five  weeks) ;  the  physician 
told  me  that  I  was  at  the  proper  spring.  At  Carlsbad  I  drank  three  half- 
glasses  of  Schlossbrunnen  daily,  and  besides  took  four  Sprudel  and  eight 
mud-baths  (one  every  third  day).  The  action  of  the  baths  was  always 
sedative  for  several  hours.  In  general  the  treatment  at  Carlsbad  affected 
my  body  quite  unfavorably,  my  strength  was  not  con^espondingly  in- 
creased, and  a  slow  improvement  could  only  be  observed  at  intervals  of 


*  [Senn.  The  Surgical  Treatment  of  Pyloric  Stenosis,  with  a  Report  of  Fifteen 
Operations  for  this  Condition.  New  York  Medical  Record,  November  7  and  14, 
1891.— Tr.] 

f  [This  prophecy  has  practically  been  fulfilled  in  the  three  cases  recently  reported 
by  Bircher  (Correspondenzbl.  fiir  schweizer  Aerzte,  Jahr.  xxi,  No.  23).  Bircher's 
method  of  operation  consists  in  exposing  and  drawing  out  the  stomach  by  an 
incision  parallel  with  the  free  border  of  the  left  ribs ;  a  fold  is  then  made  in  the 
stomach  large  enough  to  reduce  it  to  its  normal  size;  the  greater  curvature  is 
sutured  with  silk  nearly  on  a  line  with  lesser  curvature.  The  fold  hangs  within 
the  stomach.  In  one  of  the  cases  there  was  no  return  of  the  symptoms  after  thirty 
months.    See  Am.  Jour.  Med.  Sc,  1892,  vol.  ciii,  p.  333.— Tb.] 

X  Loc.  cit.,  p.  485. 


CASES  OF  DILATATION   OF  STOMACH.  159 

from  four  to  five  weeks.  After  the  10th  of  August  I  was  under  the  treat- 
ment of  another  physician." 

When  I  first  examined  this  patient,  who  was  sent  to  me  by  his  family 
physician  on  the  24th  of  October,  although  he  was  thin,  he  by  no  means 
looked  sick.  Lungs  and  heart  normal ;  liver  not  enlarged ;  its  lower  edge 
can  be  felt  distinctly  a  finger's  breadth  below  the  free  margin  of  the 
ribs.  Spleen  not  enlarged;  the  stomach,  however,  showed  the  following 
changes  :  Even  on  mere  inspection  of  the  abdomen,  and  especially  on 
looking  at  it  against  the  light,  with  the  patient  lying  down,  I  can  see  a 
slight  protuberance  the  size  of  a  five-mark  piece  [about  the  same  as  silver 
dollar]  in  the  region  of  the  umbilicus,  and  extending  to  the  right;  it  pro- 
jects so  slightly  above  the  surface  of  the  abdomen  that  it  is  ouly  recog- 
nizable by  the  relief  given  by  its  shadow.  Otherwise  the  abdominal  walls 
are  smooth,  not  too  relaxed,  with  neither  trough-like  depression  nor  ab- 
normal vaulted  projection.  Palpation  reveals  a  tumor  at  the  place  men- 
tioned, about  the  size  of  an  apple,  hard,  nodular,  easily  movable,  which 
does  not  descend  on  respiration,  and  entirely  insensitive  to  pressure.  Ta- 
pottement  produces  loud  succussion  sounds.  No  slapping  sounds  (Klatsch- 
gerdiisch).  The  inguinal  glands  are  aboLit  the  size  of  a  pea,  but  there  are 
no  other  adenopathies.  The  patient  has  taken  a  test-breakfast.  I  intro- 
duce the  stomach-tube,  and  on  expression  obtain  about  100  c.  c.  [  |  iij^]  of 
a  thin  fluid,  which  contains  some  remnants  of  the  roll.  I  now  inflate  the 
stomach  with  the  double  bulb,  and  you  can  see  that  the  tumor  is  displaced 
somewhat  to  the  right  and  downward,  and  that  the  contour  of  the  stom- 
ach becomes  very  distinct.  By  sight  alone,  but  better  by  means  of  per- 
cussion, I  can  locate  the  greater  curvature  3  centimetres  [1^  inch]  below 
the  umbilicus.  Examination  of  the  stomach-contents,  which  have  mean- 
while been  filtered,  reveals  the  total  absence  of  hydrochloric  acid,  faint 
peptone  reaction,  large  amounts  of  propeptone,  erythrodextrin,  fatty  acids, 
but  no  lactic  acid.  I  must  tell  you  that  at  a  former  examination  I  ascer- 
tained that  the  filtrate  of  the  stomach-contents  did  not  digest  albumen, 
and  that  from  the  examination  made  six  hours  after  a  dinner  consisting  of 
meat,  potatoes,  bread,  and  bouillon  the  same  results  were  obtained.  Neither 
yeast-cells,  sarcinae,  nor  cancerous  elements  are  present.  The  patient 
took  1  gramme  [gr.  xv]  of  salol  yesterday,  and  has  brought  lis  the  urine 
voided  three  quarters  of  an  houi",  an  hour  and  a  quarter,  and  an  hour  and 
three  quarters  afterward.  You  see  that  in  the  last  portion  we  get  an  in- 
distinct violet  coloration  on  adding  ferric  chloride,  but  that  I  must  first 
shake  up  the  urine  with  ether  in  order  to  obtain  a  positive  though  only  a 
weak  reaction. 

In  view  of  all  this  there  can  be  no  doubt  that  the  diagnosis  is  cancer- 
ous stenosis  of  the  pylorus,  ^vith  consecutive  dilatation  of  the  stomach. 
It  is  interesting  that  in  this  case  the  disease  began  so  insidiously,  and  that 
it  pointed  so  little  to  the  stomach  as  its  seat,  that  probably,  in  connection 
with  a  then-existing  bronchial  catarrh,  the  suspicion  of  phthisis  could 
arise,  which  led  to  his  being  sent  to  Gorbersdorf.  I  have  seen  excellent 
results  in  the  treatment  of  phthisis  in  Gorbersdorf,  but  carcinomata  can 
not  also  be  cured  there !  The  case  is  so  far  a  favorable  one  in  that,  on  the 
one  hand,  the  bodily  strength  is  relatively  good,  and,  on  the  other,  the 


160  DISEASES  OP   THE  STOMACH. 

tendency  to  decomposition  of  tlie  stomacli-contents  is  comparatively  slight. 
In  the  way  of  treatment  the  patient  has  been  taking  condurango,  with 
hydrochloric  acid,  and  for  the  past  week  his  stomach  has  been  washed  out 
regularly  every  second  evening,  six  hours  after  his  dinner;  considerable 
quantities  of  stomach -contents,  brown  in  color,  have  always  been  brought 
up.  I  i^roposed  to  the  patient  to  have  the  tumor  excised,  which,  according 
to  competent  authority,  can.  be  done  in  this  case.  However,  he  feels  so 
much  easier  and  better  under  the  present  treatment  that  he  can  not  decide 
upon  having  it  done,  and  thus,  as  is  alas  so  frequent,  the  favorable  moment 
for  undertaking  it  will  pass  by. 

The  second  case,  which  I  will  deal  with  at  less  length,  concerns  this 
fifty-two-year-old,  large,  strongly  built,  somewhat  pale  woman.  For  about 
a  year  and  a  half  she  has  suffered  severely  with  acid  eructations.  To  this 
has  been  added  a  constant  loss  of  appetite,  and  partly  owing  to  this,  partly 
because  she  has  kept  a  strict  diet,  her  nutrition  has  suffered  considerably. 
jSTo  difficulties  in  swallowng.  Vomiting  has  been  very  infrequent,  lately 
every  fortnight,  and  is  said  to  have  consisted  of  very  sour,  slimy  masses, 
mixed  with  but  slightly  changed  remnants  of  food ;  blood  has  never  been 
present.  Stools  hard  and  sluggish.  The  urine  has  been  repeatedly  exam- 
ined, with  negative  result.  The  patient  was  formerly  very  healthy,  vigor- 
ous, and  active  about  the  house,  and  has  borne  nine  children.  Although  I 
pass  over  the  examination  of  the  other  organs,  in  which  there  is  nothing 
abnormal,  I  wish  to  call  your  attention  to  the  relaxed  condition  and  mark- 
edly vaulted  projection  of  the  abdominal  walls,  on  which  I  can  at  once 
produce  loud  succussion  sounds.  I  can  not  palpate  a  tumor  anywhere, 
yet  I  feel  the  pulsations  of  the  aorta.  The  patient  "  expresses  "  a  light-brown 
fluid — she  had  some  meat  and  coffee  four  hours  ago  ;  on  inflation  with 
air  the  entire  abdominal  cavity  immediately  becomes  evenly  distended,  so 
that  we  can  see  the  lower  border  of  the  stomach  running  just  above  the 
symphysis;  the  whole  abdonaen  appears  like  an  evenly  inflated  balloon. 
The  salol  test  does  not  show  any  retardation.  The  filtrate  of  the  stomach- 
contents  has  an  acidity  of  48  per  cent  with  a  decinormal  soda  solution, 
and  distinctly  contains  free  hydi'ochloric  acid,  peptone,  only  traces  of 
propeptone;  it  also  digests  well.  Lactic  acid  is  present  in  small  quan- 
tities. 

The  diagnosis  of  gastric  dilatation,  which  can  not  be  doubted,  does 
not  seem  to  have  been  made  before.  The  question  arises.  To  what  can 
the  dilatation  be  referred?  A  previous  ulcer  may  be  rejected  with  great 
probability  on  account  of  the  absence  of  pain,  and  altogether  on  account 
of  the  previous  good  general  condition.  Thus,  also,  tumors  of  any  kind 
whatsoever  may  be  excluded,  and,  granted  that  further  observations  yield 
no  results  different  from  to-day's,  we  can  only  have  to  deal  with  a  cica- 
tricial distortion  or  adhesion,  or  with  a  primary  atony  of  the  gastric  mus- 
cular fibers.  Even  though  the  former  could  be  a  result  of  puerperal  peri- 
tonitis which  had  run  a  latent  course,  yet  this  is  only  to  be  surmised.  At 
any  rate,  the  prognosis  is  favorable  for  improvement  within  a  short  time 
in  view  of  the  presence  of  free  hydrochloric  acid.  I  have  persuaded  the 
patient,  who  has  come  from  a  distance,  to  enter  the  sanitarium,  where  I 
shall  treat  her  with  an  appropriate  dry  diet,  systematic  lavage,  strych- 


CASES   OF   DILATATION  OP   STOMACH.  161 

nine,  and  faradization  of  tlie  stomach ;  and  at  the  close  of  this  course  I 
shall  again  present  her  to  you.* 

The  third  case  I  present  is  a  young  student,  twenty-one  years  of  age, 
strong  and  apparently  healthy.  He  has  complained  for  fifteen  months  of 
distention  of  the  abdomen,  Avith  jDressure  and  fullness  there,  capricious 
appetite,  irregular  bowels,  and,  when  these  symptoms  are  present,  of  poor 
sleep,  headaches,  brief  attacks  of  dizziness,  and  conditions  of  anxiety.  He 
therefore  keeps  a  strict  diet,  refrains  from  all  Kneipei^ei,  and  tends  to 
hypochondriasis.  The  tongue  is  clean,  eructation  and  vomiting  have 
never  been  present,  the  stomach-contents  as  well  as  the  size  of  the  stom- 
ach are  normal,  and  we  would  be  inclined  to  regard  this  case  as  one  of 
nervous  dyspej)5ia,  were  it  not  that  the  iodide  of  potassium  and  salol  tests 
both  agree  in  showing  retardation  of  absorption  and  motion.  I  there- 
fore do  not  hesitate  in  pronouncing  this  a  case  of  gastric  insufficiency, 
and  the  result  of  the  treatment  adopted  seems  to  justify  the  diagnosis. 
For  two  weeks  he  has  taken  0"03  [gr.  1]  of  extract  of  nux  vomica  three 
times  daily,  and  has  been  faradized  every  other  day.  Since  this  time  the 
attacks  have  not  appeared. 

In  these  three  cases  I  believe  I  have  presented  various  types  of 
dilatation  and  insufficiency  of  the  stomach.  You  can  see  from  this 
how  the  simple  diagnosis  of  "  dilatation  of  the  stomach  "  does  not 
suffice,  and  how  much  treatment  and  prognosis  are  influenced  by 
the  recognition  of  the  underlying  cause. 

*  To  prove  to  what  errors  even  the  most  careful  single  examination  is  liable  in 
making  a  diagnosis,  I  wish  to  add,  while  correcting  the  proof-sheets,  that  after 
about  three  weeks'  observation  the  hydrochloric  acid  disapoeared  permanently,  and 
at  times  in  certain  positions  of  the  patient,  and  with  a  definite  fullness  of  the  stom- 
ach, a  small  tumor,  hardly  the  size  of  a  walnut,  was  palpable  in  the  pyloric  region. 
I  have  purposely  abstained  from  changing  anything  in  ray  former  remarks  regard- 
ing this  case.  I  have  heard  that  the  patient  died  several  months  later,  of  '•  cancer  of 
the  stomach."    (Addition  to  the  second  edition. — E.) 


LECTUKE   V. 


CANCEE   OF   THE   STOMACH. 


Gentlemen  :  Altliougli  it  may  be  interesting  to  learn,  from  the 
various  statistics  which  are  published  from  time  to  time,  that  be- 
tween 0"5  and  2*5  per  cent  of  the  total  mortality  is  due  to  cancer 
of  the  stomach,  and  that  35  to  45  per  cent  of  all  cases  of  can- 
cer involve  the  stomach,  yet  such  facts  have  only  a  nosological 
interest.  Of  far  greater  importance  is  the  question,  At  what  age  do 
persons  most  frequently  succumb  to  gastric  cancer  ?  The  various 
statistics,  of  which  Brinton's,  based  upon  600  cases,  and  Welch's, 
upon  2,0Y5  cases,  are  the  most  important,  agree  tolerably  well  in 
proving  that  three  fourths  of  all  cancers  of  the  stomach  occur  be- 
tween the  fortieth  and  the  seventieth  years  of  life.  The  maximum 
liability  is  between  the  fiftieth  and  the  sixtieth,  but,  according  to 
Lebert,  it  lies  between  the  forty-first  and  the  end  of  the  sixtieth 
year.  It  is  very  rare  before  the  thirtieth  year;  congenitally  it 
almost  never  occurs,  and  the  case  reported  by  Wilkinson  *  must  be 
regarded  as  a  very  great  rarity.  According  to  decades,  its  occur- 
rence is  as  follows : 


10  to  20. 

20  to  30. 

30  to  40. 

40  to  50. 

50  to  60. 

60  to  70. 

70  to  80. 

80  to  90. 

Welch 

Brinton . . . 

2 

55 
11 

271 
31 

55 

499 
63 

96 

620 

88 
95 

428 
100 

61 

140 
52 

13 

60 

Lebert  f.. . 

3 

1 

*  Quoted  by  W.  Hayle  Walshe.  The  Nature  and  Treatment  of  Cancer.  Lon- 
don, 1846,  p.  146.  [Other  very  early  cases  of  gastric  cancer  may  be  found  in 
Welch's  article  in  Pepper's  System  of  Medicine,  vol.  ii,  p.  534,  1885.  Dujardin- 
Beaumetz  asserts  that  all  cases  of  cancer  of  the  stomach  diagonsed  in  children  have 
been  mistakes.     Bulletin  gener.  de  therapeutique,  September  15,  1890. — Tb.] 

f  Lebert  reports  162  cases. 


HEREDITY  OF  CANCER.  163 

Thus  tlie  frequency  in  the  four  decades,  between  the  thirty-first 
and  the  completed  seventieth  year  is  94*6  per  cent.  But,  as  already 
stated,  these  figures  are  only  based  upon  the  relative  morbidity  of 
the  different  ages  to  the  total  morbidity  from  cancer.  If  the  fre- 
quency of  the  disease  Avere  calculated  for  the  total  number  of  people 
living  in  each  decade,  then  the  ratio  would  increase  in  an  ascending 
scale,  and  would  not  show  a  diminution  after  the  sixtieth  year. 
Modifying  factors  then  arise  (like  those  recently  calculated  by 
Wiirzburg  for  phthisis),  the  relative  frequency  of  which,  as  esti- 
mated for  the  total  number  of  people  living  at  that  period,  steadily 
increases  with  advancing  age. 

Sex  appears  to  exert  no  influence  on  the  frequency  of  gastric 
cancer ;  at  all  events,  Fox's  tabulation  of  the  statements  of  seven 
writers  shows  that,  of  1,303  cases,  680  were  males  and  623  females; 
in  other  words,  both  sexes  were  about  equally  affected,  if  we  allow 
for  the  coincidences  which  are  unavoidable  in  such  a  small  series. 
Ledoux-Lebard,*  from  a  study  of  the  mortality  statistics  of  Vienna, 
announces  a  mortality  which  is  about  the  same  for  both  sexes 
(100  in  25,000  deaths  in  a  city  of  a  million  inhabitants).  Of 
Welch's  2,214  cases,  1,233  were  men  and  981  women.  If  the 
general  belief  is  true  that  a  gastric  ulcer  may  be  transformed  into 
a  cancer,  and  that  ulcer  of  the  stomach  is  especially  frequent  in 
women,  then  these  statistics  (in  which  the  women  are  actually  in 
the  minority)  prove  that  this  change  is  not  of  frequent  occurrence. 

It  would  be  very  important  if  we  could  come  to  a  definite  con- 
clusion regarding  the  heredity  of  cancer.  ]^ot  alone  in  the  diag- 
nosis of  a  suspicious  case,  but  also  in  the  prognosis  as  to  the  prob- 
able duration  of  life  of  the  children  of  cancerous  parents,  an 
important  part  is  played  by  this  question  of  the  heredity  of  cancer, 
it  being  self-evident  that  cancer  of  the  stomach  is  included  in  the 
general  sphere  of  carcinomatous  affections.  All  authors  who  have 
studied  the  oi^igin  of  carcinoma,  even  to  the  most  recent  date  (a 
good  resume  of  this  discussion  will  be  found  in  J.  E.  Alberts's 
book  t),  agree  that  cancer  is  hereditary  in  the  sense  that  the  predis- 

*  Ledoux-Lebard.     Arch,  gener.  de  med.,  Avril,  1885. 

f  J.  E.  Alberts.     Das  Carcinom    in  historischer  und    experimentell-patholo- 
gischer  Beziehung.     Fischer,  Jena,  1887. 


IQ^  DISEASES  OF  THE  STOMACH. 

position  is  transmitted  from  the  sufferer  to  liis  descendants,  and  tliis 
it  is  which  may  develop  under  certain  conditions.  But  what  are 
these  conditions  which  influence  the  transmission  and  subsequent 
development  of  the  disease ;  how  often  are  the  subjects  attacked 
in  other  words,  how  frequently  do  the  children  of  carcinoma- 
tous parents  acquire  the  disease,  and  what  cause  may  be  discov- 
ered for  this  ?  This  is  really  the  practical  side  of  the  question ; 
but,  strange  to  say,  it  is  scarcely  broached  in  these  works,  while 
its  great  importance  is  manifest,  and  confronts  us  daily.  But 
here,  instead  of  positive  numerical  data,  we  are  almost  exclusive- 
ly compelled  to  use  more  or  less  subjective  (and  hence  unrelia- 
ble) opinions,  while,  the  information  obtained  from  the  relatives 
of  the  deceased  patients  is  always  interpreted  very  differently 
by  different  physicians,  yet  nearly  always  in  the  view  of  hered- 
ity. 

The  life-insurance  companies,  which,  naturally,  are  vitally  inter- 
ested in  this  question  of  the  heredity  of  cancer,  do  not,  as  a  rule, 
reject  a  candidate  on  account  of  the  death  of  one  parent  from  this 
disease ;  yet  it  is  considered  to  increase  the  risk,  and  a  higher  premi- 
um must  be  paid.  This  is  based  upon  their  practical  experience : 
thus,  for  example,  in  a  period  of  fifty  years,  from  1829  to  18T8,  the 
Gotha  Life  Insurance  Company  had  334  deaths  from  cancer;  of 
these,  31 — i.  e.,  9*3  per  cent — were  hereditary.  Even  so  experienced 
and  practical  an  observer  as  Lebert  asserts  that,  where  it  is  possible  to 
watch  the  health  of  entire  families  during  a  large  number  of  years, 
indubitable  cases  of  heredity  may  be  observed.  This  agrees  with 
the  experience  of  many  old  practitioners.  Not  alone  may  cancer 
of  the  stomach  be  directly  transmitted  from  parents  to  children, 
but  more  frequently  the  preceding  generation  has  had  a  different 
variety  of  cancer  ;  in  mothers  the  uterus  or  mam.ma  has  been  espe- 
cially frequently  involved.  In  Lebert's  cases  heredity  was  observed 
in  Y  per  cent.  "Well  known  and  frequently  quoted  is  the  case  of  the 
ISTapoleons,  of  whom  Napoleon  I,  his  father,  and  his  sister  Caroline 
died  of  gastric  cancer,  which  occurred  in  two  generations  of  the  fam- 
ily. Nevertheless,  in  this  and  similar  statements,  no  attention  is  paid 
to  the  fact  that  the  disease  often  occurs  in  families  in  which  there  is 
no  hereditary  predisposition.    H.  Snow,  physician  to  the  London  Can- 


ETIOLOGY  OF  CANCER.  165 

cer  Hospital,  *  has  answered  the  question,  to  the  effect  tliat  in  1,075 
cases  of  carcinoma  in  different  parts  of  the  body,  16T — i.  e.,  15'7 
per  cent — stated  that  the  disease  had  ah-eady  occurred  in  their  fami- 
hes,  it  being  understood  that  the  transmission  is  not  always  direct, 
but  that  it  has  affected  more  than  one  member  of  the  family.  On 
the  other  hand,  among  1T5  patients  who  were  under  treatment  for 
non-cancerous  affections,  46 — i.  e.,  26  per  cent — admitted  that  cancer 
had  occurred  in  their  families ;  and  in  two  other  series,  of  Y8  and 
Y9  cases  respectively,  the  former  being  healthy  individuals,  the 
latter  patients  with  pulmonary  diseases,  the  relative  percentages 
were  19"2  and  11'3.  It  is  manifest  that  statistics  of  this  kind  are 
very  uncertain,  since  it  can  not  be  demonstrated  whether  the  jia- 
tients  in  question  have  not  or  would  not  have  fallen  victims  to 
the  disease.  At  all  events,  the  statistics  show  that  in  a  malady 
which  occurs  as  frequently  as  carcinoma,  coincidence  may  play 
a  great  jDart  in  its  etiology ;  and  it  would  therefore  be  well  in 
an  individual  case  not  to  lay  too  great  a  stress  on  a  j)Ossible  he- 
redity. 

Etiology. — In  discussing  this  question  of  the  hereditary  trans- 
mission of  carcinoma  of  the  stomach,  I  have  already  encroached 
upon  the  question  of  the  individual  causes  of  the  disease.  In  gen- 
eral, it  must  be  admitted  that  we  are  just  as  ignorant  of  the  etiology 
here  as  elsewhere.  I  may  enumerate  a  list  of  so-called  etiological 
factors,  because  in  a  number  of  cases  we  have  observed  a  transient 
connection,  and  a  more  or  less  evident  transition,  which  is  called 
cause  and  effect ;  yet  it  is  not  known  why  these  causes  are  in  some 
cases  followed  by  a  carcinomatous  proliferation,  and  why  in  others 
there  is  no  reaction  whatsoever.  Nevertheless,  some  of  the  factors 
to  be  mentioned  presently  occur  so  frequently  that  they  must  exert 
some  influence  on  the  origin  of  carcinomatous  tumors.  A  discus- 
sion of  this  question  is  in  place  in  a  general  consideration  of  the 
nature  of  carcinoma ;  this  lies  within  the  province  of  general  j)athol- 
ogy,  and  hence  is  out  of  place  here.  The  assertion  that  Cohnheim's 
theory  of  misplaced  embryonic  cells  does  not  explain  the  origin  of 
cancer,  but  that  it  is  due  to  the  pernicious  action  of  micro-organisms, 

*  II.  Snow.     Is  Cancer  Hereditary?    British  Medical  Journal,  October  10,  1885. 


166  DISEASES  OP  THE  STOMACH. 

is  as  yet  only  a  presumption,  which  Alberts,  Schill,  and  Scheur- 
len  *  have  been  investigating  experimentally,  though  without  any 
definite  results. 

Here  I  must  refer  you  to  the  text-books  on  pathological  anatomy. 
I  must  simply  limit  myself  to  a  brief  resume  of  the  possible 
etiological  factors.  All  of  these  partake  more  or  less  of  the  char- 
acter of  irritants  which  may  be  due  to  the  ingestion  of  acrid  sub- 
stances, or  which  may  result  from  acute  or  chronic  inflammatory 
processes.  Among  these  may  be  included  corrosion  by  nitric  acid 
and  arsenic  ;  of  the  former,  Andral  is  said  to  have  reported  an  exam- 
ple, but  the  case  is  not  re]3orted  in  the  reference  which  is  copied 
from  one  book  to  another ;  the  latter  is  regarded  as  a  causal  factor 
by  Dittrich ;  yet  this  is  at  all  events  doubtful,  since  "Walshe  found 
a  large  quantity  of  arsenic  encapsulated  in  the  stomach  of  a  patient 
without  any  further  changes  in  its  tissues.f  Traumatisms  have  been 
repeatedly  cited  as  causes  of  gastric  cancer.  For  example,  Alberts  X 
reports  the  following  case :  A  man  who  up  to  his  fiftieth  year  had 
always  enjoyed  good  health  stumbled  and  fell  against  the  handle  of 
his  umbrella.  Three  weeks  later  gastric  symptoms  appeared,  and 
after  a  year  the  patient  died  of  carcinoma  ventriculi.  A  moment's 
consideration,  however,  will  show  that  this  and  similar  observations 
can  not  definitely  settle  this  question,  since  they  are  not  absolutely 
conclusive.  Who  can  tell  whether  there  was  not  already  a  latent 
cancer,  and  that  the  traumatism  simply  accelerated  its  growth  ? 

Even  in  olden  times  inflammatory  conditions  of  the  mucous 
membrane  of  the  stomach  were  included  among  the  causes  of  gastric 
carcinoma.  Such  views  may  be  found  in  the  writings  of  Boerhaave 
and  Yan  Swieten,  and  in  the  older  works  they  are  met  with  more 
frequently  in  proportion  as  the  nature  of  the  disease  is  less  known. 
But  very  recently  Schuchardt,*  in  a  monograph  entitled  Contribu- 
tions to  the  Origin  of  Carcinoma  from  Chronic  Inflammatory  Condi- 
tions of  the  Mucous  Membranes  and  Skin,  claims  that  a  chronic  or 


*  Alberts,  loc.  cit.,  pp.  183  et  seq  — Scheiirlen.     Verhandlungen  des  Vereins  fiir 
innere  Med.  vom  28.  Nov.,  1887,  in  Deutsche  med.  Wochenschr.,  No,  48, 

+  Walshe,  loc.  cit,  p.  167. 
X  Alberts,  loc.  cit.,  p.  195. 

*  Schuchardt.     Beitrage,  etc.    Volkmann's  Sainmlung  klin.  Vortrage,  No,  257, 


ETIOLOGY  OF  CANCER.  167 

hyperplastic  condition  precedes  the  formation  of  the  neoplasm,  and 
that,  while  this  condition  does  not  necessarily  cause  the  latter,  yet  it 
favors  it  to  a  high  degree. 

Chronic  gastric  ulcers  may  also  be  classed  among  the  predis- 
posing factors,  Lebert  has  observed  the  direct  transformation  of 
ulcer  into  cancer,  and  Dittrich  the  simultaneous  occurrence  of  both 
conditions.  Brinton  cites  cases  in  which  the  lesion,  macroscopically 
an  ulcer  with  thickened  edges,  was  accompanied  by  unquestion- 
able metastases  in  the  liver  and  lungs;  and  even  states  that  "an 
unhealed  ulcer  may  at  times  cause  the  development  of  cancerous 
cachexia."  *  C.  Meyer  f  describes  a  case  of  simple  ulcer  occurring 
with  carcinoma  of  which  the  cell-nests,  although  only  in  the  imme- 
diate vicinity  of  the  ulcer,  were  visible  as  smooth  nodules  which 
had  developed  from  the  epithelium  of  the  ducts  of  the  glands. 
Heitler  :|:  reports  three  similar  cases  (without  microscopic  examina- 
tion), and  remarks  that  the  diagnosis  carcinoima  ventriculi  ad  hasim 
ulceris  rotundi  is  not  at  all  rare  in  Yienna.  Hauser  *  has  histo- 
logically demonstrated  the  transition  of  ulceration  into  carcinoma- 
tous proliferation,  and  asserts  that  in  one  of  the  cases  examined  by 
him  he  found  not  only  the  secondary  development  of  carcinoma  in 
a  gastric  ulcer  of  very  long  standing,  but  that  "  occasionally  a  can- 
cer may  develop  from  an  affection  of  the  gastric  glands,  even  in  the 
sense  of  the  theory  proposed  for  carcinoma  by  Thiersch  and  Wal- 
deyer."  Flatowl  reports  a  similar  case  from  the  Pathological 
Institute  at  Munich.  This  case  is  important  because  the  patient 
was  only  twenty-six  years  old,  and  the  history  of  ulcer  was  beyond 
doubt.  T]ie  cancer  was  near  the  pylorus,  and  in  its  center  was  an 
old  scar  with  a  smooth  base.  As  the  result  of  his  microscopical  ex- 
amination Flatow  says,  "  Evidently  there  was  at  first  a  cicatricial 
mass,  and  this  facilitated  an  atypical  proliferation  of  epithelium." 

*  Brinton,  loc.  cit.,  p.  243. 

f  C.  Meyer.  Ein  Fall  von  Ulcus  simplex  in  Verbindung  mit  Carcinom.  Inaug. 
Dissertation.     Berlin,  1874. 

X  Heitler.  Entwickelung  von  Krebs  auf  narbigem  Grunde  in  Magen  nnd  in  der 
Gallenblase.     Wiener  med.  Wochensehr.,  1883,  No.  31. 

*  Hauser.  Das  chronisehe  Magengeschwiir  und  dessen  Beziehung  zur  Entwick- 
elung des  Magencarcinoms.     Leipzig,  1883,  S.  70  und  73. 

I  H.  Flatow.  Ueber  die  Entwickelung  des  Magenkrebses  aus  Narben  des  run- 
dcn  Magengeschwiirs.     Inaug.  Dissert.     Miinchen,  1887. 


1(58  DISEASES  OF  THE  STOMACH. 

Concerning  the  other  chronic  irritants  of  the  mucous  membrane 
which  are  supposed  to  favor  the  development  of  cancer,  the  various 
exceptions  are  so  evident  that  a  discussion  on  the  unrehability  of 
such  evidence  is  superfluous.  In  Beau's  statement  that  gastric  can- 
cer is  often  preceded  by  a  period  of  "  idiopathic  dyspepsia,"  *  the 
word  often  ought  to  be  changed  to  seldom.  For,  on  the  contrary, 
it  is  surprising  how  frequently  the  patients  assert  that  thej^  have 
always  had  sound  stomachs,  and  that  they  have  always  been  moder- 
ate in  eating  and  drinking.  While  the  gluttons  have  themselves  to 
blame  to  some  extent  for  their  dilated  stomachs,  the  unfortunate  suf- 
ferers from  gastric  cancers  have  not  even  the  melancholy  satisfac- 
tion that  in  the  days  of  health  their  stomachs  at  least  afforded  them 
especial  joy  and  pleasure  ! 

Pathological  Anatomy. — I  shall  refrain  from  giving  exact  details 
of  the  histological  features  of  carcinoma  of  the  stomach,  as  my  ex- 
perience on  this  subject  has  only  been  an  ordinary  one,  and  I  can 
only  repeat  the  facts  which  you  will  find  more  or  less  thoroughly 
described  in  many  books.  After  a  thorough  investigation,  Wal- 
deyer  was  the  first  to  teach  that  the  disease  is  developed  from  the 
glandular  elements  of  the  mucous  membrane— i.  e.,  from  the  peptic 
glands,  and  especially  from  the  mucous  glands  of  the  pylorus.  The 
process  is  an  atypical  glandular  proliferation  which  bursts  through 
the  muscularis  mucosae,  and  extends  into  the  submucosa.  Here  cir- 
cumscribed cancerous  nodules  are  formed ;  these  coalesce  later  on, 
and  thus  necessitate  the  subsequent  flattened  growth.  Coincidently 
there  is  an  active  growth  of  the  connective  tissue  which  soon  ex- 
ceeds the  proliferation  of  the  glandular  elements,  and  thus  at  first 
produces  an  hypertrophy  of  the  connective  tissue,  while  the  glandu- 
lar elements  still  remain  normal.  Later,  it  extends  along  the  pro- 
liferated glandular  tubules  and  manifests  itself  as  a  small-celled  in- 
filtration about  the  cancer  nodules.  This  growth  of  the  connective 
tissue  appears  to  exert  a  decided  influence  in  determining  whether 
the  developirig  cancer  will  be  of  the  schirrus,  encephaloid,  or  colloid 
variety.  But,  as  I  have  already  said,  I  merely  wish  to  mention 
these  things  superficially,  and  shall  simply  recall  that  any  of  the 


*  Beau.    Gazette  d.  hopit.,  1859,  p.  390. 


VARIETIES  OP  CANCER.  169 

various  forms  of  cancer — schirrus,  ence/phaloid,  colloid,  polypoid, 
and  telangiectatic — may  occur  in  the  stomach.  All  authors  state 
that  the  first  is  the  most  common :  according  to  Brinton,  it  occurs 
in  Y5  per  cent  of  all  cases,  while  the  colloid  is  found  only  in  from  2 
to  8  per  cent.  If  we  agree  with  Waldeyer,*  that  the  nature  of  the 
disease  consists  in  "  an  atypical  transformation  of  epithelium,"  then 
the  above-mentioned  individual  varieties  are  one  and  the  same  fun- 
damental process,  and,  as  actually  occurs,  often  change  into  one 
another. 

Scirrhus,  carcinoma  simplex  or  Jibrosum,  with  its  predominant 
development  of  dense  connective-tissue  stroma,  and  with  relatively 
few  cell-nests,  has  a  firm  and  compact  structure.  It  occurs  some- 
times as  large  masses  or  tubercles,  sometimes  as  small  nodules ;  at 
times  multiple,  but  oftener  as  a  diffuse  infiltration.  It  creaks  when 
cut,  and  the  section  presents  an  almost  cartilaginous  tissue  of  a 
white,  grayish-yellow,  or  dull  yellow  color,  with  yellow  or  red 
spots  scattered  here  and  there ;  it  may,  however,  have  a  smooth 
and  shining  surface,  almost  like  bacon. 

Where  there  is  a  tendency  to  ulceration  we  find  a  rich  vascular 
network,  and  also  an  extensive  diffuse  redness ;  where  ulceration 
has  already  begun,  an  undulating  fissured  surface  is  presented  by 
the  ulcer,  which  is  covered  with  ragged  greenish-yellow  or  black 
detritus.  Of  frequent  occurrence  are  fatty  degeneration  and 
atrophy  in  some  parts,  while  in  others  it  continues  to  grow.  Firm 
pressure  will  cause  a  small  amount  of  turbid,  milky  cancer  juice  to 
exude. 

Encephaloid  cancer,  carcinoma  medidlare,  is  soft,  has  very  little 
connective-tissue  stroma,  but  is  very  rich  in  vessels  and  cells ;  the 
growth  is  spongy,  and  cuts  easily ;  the  cut  section  is  whitish-yellow 
in  color,  and  resembles  brain  matter  both  in  color  and  consistency. 
It  undergoes  colloid  degeneration  more  frequently  than  does  the 
scirrhus.  Extravasations  of  blood  are  frequent,  and  are  marked  by 
their  characteristic  discoloration. 

If  the  cells  in  an  otherwise  well-developed  stroma  show  from 


*  Waldeyer.      Die  Entwickelimg  der  Carcinome.     Virchow's  Archiv,  Bd.  Iv, 
S.  54. 


170  DISEASES  OP  THE  STOMACH. 

the  beginning  a  tendency  to  undergo  colloid  degeneration,  then  the 
whole  growth  assumes  a  gelatinous  appearance  somewhat  resem- 
bling glue.  Thus  arises  the  colloid  carcinoma,  carcinoma  alveo- 
lare  or  galatinosum.  On  cutting  and  scraping,  a  true  cancer  juice 
does  not  exude,  but  instead  gelatinous  fragments. 

Yillous  carcinoma,  ZottenTirebs,  carcinoma  villosutn,  is  pro- 
duced by  villous  or  papillary  outgrowths  in  the  scirrhus  or  medullary 
varieties.  If  the  development  of  blood-vessels  predominates,  the 
growth  is  called  a  telangiectatic  carcinoma  ov  fxingus  Jiciematodes. 
Finally,  if  there  are  numerous  haemorrhages  into  the  cancerous 
tissues,  any  of  the  varieties  of  the  neoplasm  may  assume  the  charac- 
ter of  a  melanotic  carcinoma.^  As  I  have  already  indicated,  these 
various  forms  may  coexist  in  almost  every  variety. 

In  all  these  types  the  bundles  of  muscular  fibers  are  more  or 
less  infiltrated,  and  undergo  hypertrophy ;  the  muscularis  becomes 
paler,  less  elastic,  and  fragile ;  at  times,  however,  atrophy  may 
result.  Secondary  inflammatory  processes,  with  thickening  and 
adhesions  to  the  adjacent  organs,  are  observed  in  the  serosa. 

Having  thus  briefly  recalled  to  mind  the  chief  characteristics  of 
the  different  varieties,  I  shall  now  speak  more  in  detail  of  the  topo- 
graphical features  or  the  localization  of  cancer  of  the  stomach,  and 
of  the  results  thereof. 

We  must  first  distinguish  between  tumors  which  grow  especially 
on  the  surface,  and  involve  large  areas  of  the  mucous  membrane, 
and  those  which  attack  only  a  small  portion.  The  former  are  by 
far  the  less  common,  and  are  usually  of  the  medullary  or  colloid 
variety ;  they  are  characterized  by  a  nodular  or  roughened  surface 
like  a  grater  ;  they  are  flattened  rather  than  projecting  high  above 
the  surface ;  other  peculiarities  are  the  frequency  of  assuming  the 
villous  form,  the  occurrence  of  blood  extravasations  and  adhesions 
to  the  adjacent  organs,  especially  to  the  peritonaeum  and  omentum. 
In  such  cases  the  greater  portion  of  the  stomach  from  the  cardia  to 
the  fundus  may  be  converted  into  a  carcinomatous  mass,  yet  such 

*  [Such  discolored  cancers  ought  not  to  be  confounded  with  true  melanotic  tu- 
mors. Welch  could  find  no  record  of  true  primary  melanotic  cancers  of  the  stom- 
ach ;  all  of  those  cases  have  proved  to  be  melanotic  sarcomata.  Welch,  loc.  cit.,  p. 
561,  foot-note.— Tr.] 


SITUATION   OF   CANCER.  171 

an  occurrence  is  a  great  rarity.  Otherwise,  the  greater  curvature 
nsiiallj  remains  free,  and  the  neoplasm  preferably  extends  on  the 
posterior  wall  along  the  lesser  curvature.  Generally  the  organ  is 
not  increased  in  size,  but  rather  diminished  to  a  iirm,  sausage-like 
tumor.  I  have  preserved  such  a  medullary  cancer  involving  the 
entire  organ,  which  I  obtained  at  an  autopsy ;  the  capacity  of  the 
viscus  was  scarcely  200  c.  c.  [f  §  vjss.]  of  water.  The  scirrhus  variety 
involves  the  whole  organ  much  less  frequently ;  such  a  case  is  pict- 
ured in  Fig.  19,  which  is  taken  from  Carswell's  Atlas.  *  Usually 
scirrhus  follows  the  second  of  the  above  courses — i.  e.,  it  remains  in 
a  circumscribed  portion  of  the  stomach,  and  tends  to  grow  in  depth 
and  height  as  opposed  to  the  superficial  extension  of  the  medullary 
and  colloid  varieties.  This,  however,  does  not  exclude  its  multiple 
occurrence  in  several  parts  of  the  mucous  membrane  of  the  organ,  as, 
for  example,  at  the  pylorus  and  the  lesser  curvature  or  the  cul-de-sac. 

Concerning  the  situation  of  the  cancer,  nearly  all  the  statistics 
agree  that  in  about  one  half  of  the  cases  the  pylorus  is  involved : 
according  to  Brinton,  60  per  cent ;  Lebert,  59 '6  per  cent ;  Katzenel- 
lenbogen,f  58'3  per  cent ;  Luton, :{:  5Y  per  cent,  etc.  In  between 
10  and  11  per  cent  (Luton,  Y"8  per  cent)  it  is  the  cardia  or  the  lesser 
curvature ;  in  the  remainder  the  lesion  is  scattered  over  the  greater 
and  lesser  curvatures.  The  fundus  is  attacked  least  frequently  of 
all ;  such  a  case  with  extension  to  the  spleen  was  described  by  Tiin- 
gel.  *  Among  the  1,300  cases  reported  by  Welch,  19  were  situated 
in  the  fundus.  At  all  events,  the  orifices  are  the  favorite  sites — TO 
to  75  per  cent ;  thus  cancer  differs  markedly  from  ulcer  in  this 
respect,  as  the  latter  involves  the  orifices  about  five  times  less  fre- 
quently— i.  e.,  16  to  18  per  cent. 

The  situation  and  extent  as  well  as  the  consistency  of  the  neo- 
plasm influence  the  shape  and  position  of  the  stomach  in  the  follow- 
ing ways : 

*  [Sir  Robert  C.  Carswell.  Pathological  Anatomy.  Illustrations  on  the  Ele- 
mentary Forms  of  Diseases.     London,  1833-'38. — Tr.] 

f  Katzenellenbogen.  Beitrage  zur  Statistik  des  Magencareinoms.  Inaug.  Dis- 
sert., Jena,  1878. 

X  Luton.     Nouv.  dictionnaire  de  med.     Paris,  1871. 

*  Tiingel.  Klinische  Mittheilungen  aus  dem  Hamburger  Krankenhause,  1860, 
S.  108. 


172 


DISEASES   OF   THE   STOMACH. 


Fig.  19. — Scirrlius  ventriculi  totalis  (reduced  to  one  fifth). 


CHANGES   IX   STOMACH.  173 

1.  The  viscus  may  become  smaller  by  a  concentric  contraction, 
as  wliere  a  firm  tumor  involves  the  stomach  in  toto — i.  e.,  infiltra- 
tion of  the  mucosa  and  muscularis  ;  or,  finally,  even  a  narrowing  of 
the  lumen  by  extension  inward,  as  shown  in  Fig.  19.  It  may  also  re- 
sult from  tight  strictures  situated  at  the  cardia ;  as  a  consequence  of 
this,  the  absence  of  the  normal  pressure  of  the  contents  of  the 
stomach  upon  its  walls  causes  the  organ  to  contract  into  the 
smallest  possible  volume,  since  it  must  yield  to  its  elastic  tissues ;  its 
diameter  may  be  diminished  to  that  of  the  large  intestine,  as  oc- 
curred in  a  case  reported  by  Canstatt.*  The  following  drawing 
(Fig.  20)  was  made  by  me  from  a  case  which  I  had  under  observation. 
While  the  patient  was  alive  the  pancreas  and  stomach  could  be  pal- 
pated through  the  relaxed  abdominal  wall  as  a  hard  nodular  tumor. 

2.  Dilatation  is  always  the  result  of  a  tumor  obstructing  the 
pylorus.  Here  the  stenosis  may  be  due  to  all  the  various  causes 
which  have  been  fully  described  under  dilatation  of  the  stomach. 

3.  Changes  in  theposition  of  the  stomach  are  produced  by  the 
weight  of  the  tumor ;  this  may  be  so  marked  that  either  the  fundus 
or  the  pylorus  alone  or  both  together  may  be  dragged  down  deeply 
into  the  pelvis,  and  may  contract  adhesions  with  its  organs,  the 
ovaries,  uterus,  bladder,  etc. 

4.  Distortions^  hends,  and  constrictions  of  the  stomach  may  be 
developed  as  a  consequence  of  the  inflammatory  adhesions  with 
adjacent  viscera,  or  of  the  extension  of  the  new  growth  in  the 
stomach  itself. 

These  different  conditions  show  in  what  varied  ways  the  shape 
and  situation  of  the  stomach  may  be  altered. 

Gastric  cancer  occurs  so  overwhelmingly  frequently  as  a  pri- 
mary growth  that  a  case  like  that  reported  by  Cohnheim,  in  which 
the  primary  tumor  was  situated  in  the  mamma,  must  always  be  con- 
sidered a  very  great  rarity. f  On  the  other  hand,  it  is  not  exactly 
rare  to  find  the  disease  occurring  simultaneously  in  a  remote  organ 
'- — as,  for  example,  cancer  of  the  stomach  may  coexist  with  a  similar 

*  Canstatt.     Klinische  Rtickblicke.     Erlangen,  1851,  S.  178. 

f  [Thus  far  thirteen  cases  of  secondary  carcinoma  of  the  stomach  have  been 
reported.  See  J.  S.  Ely,  A  Study  of  Metastatic  Carcinoma  of  the  Stomach.  Ameri- 
can Journal  of  the  Medical  Sciences,  June,  1890,  p.  584. — Tr.] 


174 


DISEASES   OP   THE   STOMACH. 


growth  in  the  uterus  or  ovaries,  and  no  evidence  can  be  found  to 
indicate  a  metastasis  from  either  organ.     Dittrich  lias  never  seen 


»s-nc. 


Fig.  20. — Carcinoma  of  the  Cardia.  Contraction  of  the  Stomach.    Mr.  T.  died  April  10,  1885. 
«,  stomach  ;  d  duodenum  ;  ^,  pancreas  ;  tc^  transverse  colon ;  c/c,  descending  colon. 

the  simultaneous  occurrence  of  the  disease  in  the  stomach  and 
uterus.  Recently  I  performed  an  autopsy  in  a  case  in  which  there 
was  found  an  immense  cysto-sarcoma  of  the  uterus,  and  a  carcinom- 
atous infiltration  of  the  pylorus.  Secondary  cancerous  metastases 
are,  as  is  well  known,  by  no  means  rare ;  they  may  affect  any  part 
of  the  organism  in  about  three  out  of  four  cases.      The  liver  is 


CANCEROUS  METASTASES.  I75 

involved  in  25"G  to  30  per  cent;  the  peritonseiim  in  13"Y  to  22'Y  per 
cent ;  tlie  lungs  and  pleurae  in  0'6  to  6*2  per  cent ;  while  in  160  cases 
collected  by  Dittrich  the  rectum  was  involved  only  twice  and  the 
ovaries  once.  However  arbitrary  such  figures  may  be,  according  to 
the  cases  at  the  disposal  of  individual  writers,  the  evidence  as  to 
relative  frequency  of  these  metastases,  as  given  by  Lebert,  is  as 
follows :  in  the  liver,  40*9  per  cent ;  peritonaeum,  37"5  per  cent ; 
lungs,  8-3  per  cent;  ovaries,  4*5  per  cent.  Lange's*  analysis  of  210 
cases  at  the  Berlin  Pathological  Institute  gives  different  percent- 
ages: 30"9,  IT'6,  0*71,  and  0*14,  respectively.  Of  greater  practical 
interest  is  the  simultaneous  occurrence  of  metastases  in  imjjortant 
organs ;  as,  for  example,  in  the  liver  and  lungs,  which  Lange  found 
ten  times — i.  e.,  4*7  per  cent.  Although  Brinton  asserts  that  the 
occurrence  of  metastases  in  the  liver  naturallv  lessens  the  danger 
of  involvement  of  the  lungs,  yet  it  would  seem  more  probable 
that,  with  the  establishment  of  two  cancerous  depots,  the  chances 
of  infection  by  transportation  through  the  vascular  system  would  be 
increased.  I  must  confess,  however,  that  my  own  experience  cor- 
roborates Brinton's  statement. 

That  cancer  and  tuberculosis  do  not  exclude  each  other,  or  that 
both  may  perhaps  be  attributed  to  a  scrofulous  diathesis,  as  was 
formerly  supposed,  needs  no  further  discussion  at  present.  Dis- 
regarding statistical  data — as  for  example,  Lange,  who  found  them 
together  in  8-1  per  cent  of  his  cases — all  doubt  on  the  subject  has 
been  removed  by  the  direct  observation  of  tubercle  bacilli  in  the 
pulmonary  deposits  in  lungs  which  are  also  cancerous.  It  nmst  be 
confessed,  however,  that  it  is  at  times  very  difficult  to  decide 
whether  small  cavities  are  due  to  softening  of  tubercular  or  metas- 
tatic carcinomatous  nodules. 

In  many  cases  we  can  explain  the  path  of  the  metastatic  infec- 
tion by  way  of  the  blood  or  lymph  vessels;  in  others  we  must 
think  of  direct  extension  in  the  continuity  or  along  extra-vascular 
channels;  as,  for  example,  the  extension  of  a  pyloric  cancer  to 
the  edge  of  the  liver  or  the  gall-bladder ;    the  involvement  of  the 


*  Lange.     Der  Magenkrebs  und  seine  Metastasen.      Inaxig.  Dissert.     Berlin, 

1877. 

12 


^r^Q  DISEASES  OP  THE  STOMACH. 

colon  from  a  tumor  on  the  greater  curvature,  or  of  the  diapliragm 
and  lungs  from  one  situated  at  the  cardia  (Carswell  and  Yirchow  *). 
T/ie  formation  of  thrombi  in  various  places  remote  from  the 
stomach  is  also  to  be  explained  by  vascular  transportation  in  so  far 
as  thej  are  not  due  to  the  cachexia,  the  altered  condition  of  the  blood, 
and  the  slowing  of  the  circulation,  just  as  is  seen  in  the  veins  of  the 
lower  extremities.  It  has  been  repeatedly  asserted  that  the  com- 
position of  the  blood  is  altered,  esj^ecially  a  lessening  of  the  num- 
ber of  the  red  blood  cells,  and  of  the  solid  constituents  of  the 
plasma.  I  shall  consider  this  topic  further  when  discussing  the 
symptomatology.  Andral  and  Gavarettf  state  that  the  percentage 
of  iibrin  is  variable.  There  is  nothing  characteristic  in  these 
changes,  but  they  are  more  or  less  peculiar  to  all  cachectic  con- 
ditions. 

Tlie  swelling  of  the  lymjyhatic  glands  occurs  less  frequently  in 
this  disease  than  in  neoplasms  elsewhere  which  are  in  close  con- 
nection with  the  lymphatic  system — for  example,  the  mammary 
gland.  Brinton  has  observed  it  in  only  23"5  per  cent  of  his  cases, 
although  "Welch  gives  a  higher  figure,  35  per  cent.  We  must,  how- 
ever, distinguish  between  a  simple  sw^elling  and  cancerous  degenera- 
tion of  the  glands.  The  latter  would  be  observed  much  more  fre- 
quently if  attention  were  not  alone  paid  to  the  glands  which  are 
visible  and  palpable,  but  also  to  the  entire  lymphatic  system.  Lebert 
gives  the  high  percentage  of  54'5,  though  Katzenellenbogen  places 
it  lower,  40  per  cent.  The  swelling-  of  the  supraclavicular  glands, 
W'hich  was  first  claimed  by  Henoch  and  Yirchow,  and  later  by  many 
others,:};  to  be  a  pathognomonic  symptom,  is,  in  my  ex23erience,  a 
rare  and  by  no  means  constant  occurrence. 

Ulceration  occurs  to  a  very  variable  extent  in  gastric  cancer, 
sometimes  as  simple  superficial  erosions,  sometimes  as  a  single  round 
or  oval  ulcer,  not  infrequently  having  an  orifice  like  a  crater  with 
a  thick,  wall-like  edge.  Ulceration  occurs  most  frequently  in  the 
medullary  variety,  less  often  in  the  scirrhus,  and  least  of  all  in  the 

*  Virchow.     Die  krankhafte  Geschwulste,  I,  S.  54. 
f  Andral  et  Gavarett.     Rech.  sur  la  composit.  du  sang,  p.  238. 
X  Troisier.     Les  gangliones  sus-claviculaires  dans  le  cancer  de  I'estomac.     Gaz. 
hebdom.,  1886,  No.  42. 


SYMPTOMS  OF  CANCER.  177 

colloid.  Altliougli  the  process  usually  lias  a  progressive  tendency, 
yet  sometimes  carcinomatous  ulcers  may  be  found  witli  the  central 
portion  cicatrized  (whence  the  saying  that  cancer  is  curable),  but  in 
the  ede-es  of  which  new  foci  continue  to  be  formed.  Erosion  of 
the  blood-vessels  may  lead  to  small  or  large  haemorrhages  with  their 
subsequent  tissue-changes.  If  the  mucous  membrane  is  totally  de- 
stroyed, we  then  find  the  submucous  connective  tissue  covered  with 
florid,  blackish  fragments  of  the  destroyed  membrane,  or  its  surface 
may  be  entirely  bare,  excepting  here  and  there  a  few  vascular  loops. 
In  a  similar  way  arise  the  villous  fungosities  on  the  surface  of  an 
ulcerated  carcinoma ;  yet  these  must  be  carefully  distinguished  from 
the  benign  true  polypi  of  the  mucous  membrane. 

Ulceration  may  lead  to  perforation^'  this  is  comparatively  infre- 
quent. Brinton  estimates  its  occurrence  at  about  4  cent.  The  in- 
testines and  peritonaeum  are  most  frequently  involved,  especially  the 
transverse  colon ;  these  communications  being  sometimes  of  a  fairly 
large  size.  If  an  adhesive  peritonitis  has  preceded,  the  perforation 
may  at  times  lead  to  the  formation  of  an  encapsulated  sac,  which  in 
rare  cases  may  perforate  the  abdominal  wall  in  the  form  of  an  ab- 
scess. Altogether  sixteen  such  cases  have  been  reported,  according  to 
a  compilation  by  Mislowitzer  ;  *  to  these  must  be  added  another  case, 
which  occurred  in  Gerhardt's  clinic.  Dittrich  has  seen  a  case  in 
which  the  perforation  was  into  the  ileum  after  complete  closure  of 
the  pylorus  had  taken  place ;  and  thus  by  natural  means  a  collateral 
communication  between  the  stomach  and  intestines  was  established, 
such  as  we  endeavor  to  obtain  by  operation  in  similar  cases. 

General  Clinical  History. — Cancer  of  the  stomach  is  an  exceed- 
ingly insidious  disease,  and  at  the  outset  is  not  to  be  distinguished 
from  other  affections  of  the  organ  which  lead  to  dyspejjsia.  Brin- 
ton's  epigrammatic  description,  "  Obscure  in  its  symptoms,  frequent 
in  its  recurrence,  fatal  in  its  event,"  is  true  even  to-day  in  spite  of 
the  great  improvement  in  our  diagnostic  and  therapeutic  resources. 
Irregularity  and  impairment  of  the  appetite,  slowing  and  disturb- 
ance of  digestion,  a  feeling  of  pressure,  fullness,  and  tension  in  the 


*  E.  Mislowitzer.     Ucbcr  die  Perforationen  des  Magenearcinoms  naeh  aussen. 
Berlin,  1889. 


1Y8  DISEASES  OP  THE  STOMACH. 

epigastrium,  also  regurgitation  of  food  and  a  tendency  to  nausea, 
together  with  more  or  less  obstinate  constipation,  open  the  scene. 
It  is  only  gradually  that  pain  in  the  stomach,  local  or  diffused  or 
cardialgic  in  character,  is  added  ;  then  vomiting  occurs,  usually 
without  any  great  exertion  and  without  marked  nausea.  The  tongue 
becomes  thickly  coated,  and  especially  in  the  morning  has  a  tena- 
cious w^hite  fur,  which  is  scraped  ofE  with  difficulty  and  is  soon  re- 
newed. Lebert  seldom  found  the  tongue  coated,  and  considered 
this  cleanness  of  the  tongue  one  of  the  most  important  paradoxical 
manifestations  of  the  disease.  My  experience  is,  however,  different ; 
I  have,  indeed,  seen  patients  whose  tongues  remained  relatively 
clean,  yet  such  cases  are  exceptions.  The  coated  condition  of  the 
tongue  either  in  toto,  or  with  the  exception  of  the  edges  and  isolated 
papillse  which  project  like  berries,  is,  quite  on  the  contrary,  to  be 
regarded  as  an  important  point  in  the  differential  diagnosis  from 
gastric  ulcer.  A  striking  repugnance  toward  meat,  and  other  anoma- 
lies of  taste  and  appetite,  precede  complete  anorexia.  (One  of  my 
patients  stated  that  claret  suddenly  tasted  like  ink.  One  of  Brin- 
ton's  patients  abruptly  lost  all  desire  for  smoking,  although  strongly 
addicted  to  the  habit.  This,  combined  with  a  cachectic  appearance, 
led  the  physician  to  diagnose  a  cancer  which  was  subsequently  dem- 
onstrated, although  the  other  symptoms  did  not  indicate  it.*)  The 
taste  becomes  flat  and  "  pasty,"  bitter  or  sour,  or  the  mouth  may 
become  foul  in  spite  of  all  attempts  at  rinsing  and  cleansing.  The 
pain  becomes  more  intense,  and  at  times  paroxysmal,  and  occurs  not 
only  after  the  scanty  meals  but  also  between  them  and  at  night. 
Yomiting  is  more  frequent ;  while  at  first  the  vomit  consists  chiefly 
of  mucus,  remnants  of  food,  and  watery  fluid  mixed  with  bile,  in 
time  the  food  is  vomited  in  a  more  and  more  undigested  condition. 
The  vomit  is  sometimes  tasteless,  sometimes  sour,  has  a  penetrating 
or  ofi^ensive  odor,  and  where  perforation  has  occurred  into  the  in- 
testines it  may  even  have  a  fecal  odor.  Besides  containing  various 
kinds  of  epithelium  and  micro-organisms  (Fig.  21),  the  vomited  mat- 
ter may  often  contain  blood,  either  in  small  amounts  as  bright-red 


*  Loc.  cit.,  p.  195.    Although  Brinton  considers  this  diagnosis  a  "  matter  of  pro- 
fessional instinct,"  yet  it  strikes  me  as  having  been  more  a  "  matter  of  hazard  "  ! 


VOMIT  IN  CANCER. 


179 


streaks  in  the  mucus,  or  in  large  quantities  as  briglit-red  or  brown- 
isli-red    clots   or   brown,  cliocolate-colored   to    black    coagula    and 


Fig.  21. 


masses  —  the  well-known  coffee -ground  vomit;  these  differences 
are  due  to  the  length  of  time  the  blood  has  remained  in  the 
stomach,  and  to  the  extent  of  the  decomposition  caused  bj  its 
contents. 

The  vomit  from  which  this  drawing-  was  made  consisted  of  a  clear,  red- 
dish fluid,  with  a  light,  flocculent  deposit,  in  which  dark-brown  particles 
resembling  snuff  were  suspended.  The  filtrate  contained  no  free  acid, 
but  small  amomits  of  lactic  acid  were  present ;  has  no  digestive  action 
unless  hydrochloric  acid  is  added.  Under  the  microscope  may  be  seen  the 
outlines  of  red  blood-cells,  granular  masses  stained  with  blood-pigment, 
epithelium  of  the  oesophagus  and  stomach — some  of  which  look  like  peptic 
cells,  others  are  distinctly  cylindrical.  There  are  also  yeast-cells,  and 
also  cells  of  another  variety  of  fung-i  (Hyphomyceten),  probably  an  asper- 
gillus.  A  dense  network  of  delicate  and  coarse  fungus  filaments  (which 
is  merely  indicated  in  the  figure)  incloses  the  above-mentioned  brownish 
detritus  which  is  visible  to  the  naked  eye.  There  are  also  many  cocci  and 
drops  of  fat.  The  peculiar  fibers  to  the  left  of  the  figure,  resembling-  elastic 
fibers  of  the  lungs,  are  from  the  connective  tissue  of  the  ingested  meat.  I 
have  repeatedly  observed  these  fibers,  even  in  the  artificial  digestion  of 
meat.  The  patient  asserted  that  he  had  taken  only  milk  for  three  weeks. 
There  is  no  reason  to  doubt  the  truth  of  this  assertion ;  what  we  find  sim- 
ply proves  how  long  such  remnants  may  remain  in  the  folds  of  the  mucous 
membrane. 


180  DISEASES  OF  THE  STOMACH. 

The  coffee-ground  vomit  is  not,  as  was  formerly  supposed,  pa- 
thognomonic of  cancer  of  the  stomach ;  yet  it  must  be  admitted 
that  in  this  disease  the  blood  remains  in  the  stomach  for  a  longer 
period  than  in  the  other  diseases  of  this  organ  which  lead  to  hsem- 
orrhages  and  these  subsequent  changes. 

In  most  cases  there  now  appears  a  palpable  (or  also  visible)  tumor, 
which  is  most  frequently  situated  in  the  triangle  formed  by  the  free 
lower  border  of  the  ribs  and  the  linea  umbilicalis  [a  horizontal  line 
passing  through  the  umbilicus]  ;  it  is  somewhat  higher  in  men  than 
in  women,  in  whom  the  lower  situation  is  due  to  the  downward  dis- 
placement of  the  liver. 

Rather  early,  and  not  at  all  proportional  to  the  subjective  feel- 
ings of  the  patient,  occur  marked  loss  of  strength  and  j)rogressive 
emaciation ;  the  superficial  fat  and  the  muscles  rapidly  waste  away, 
till  the  sufferer  soon  drifts  into  a  state  of  extreme  marasmus  and  ex- 
haustion. One  of  my  patients,  with  a  distinct  tumor  but  with  a  sur- 
prisingly good  subjective  condition,  complained  only  at  first  that 
his  limbs  wei'e  becoming  weak  in  climbing  stairs.  Soon  the  charac- 
teristic pale-yellow  color  of  the  cancerous  cachexia  makes  its  ap- 
pearance. After  severe  haemorrhages  the  countenance  acquires  an 
anaemic  or  at  times  a  dropsical  puffiness,  especially  under  the  eye- 
lids. The  eyes  sink  in,  the  cheeks  become  very  prominent,  the 
features  pointed,  and  the  patients  look  much  older  than  they  are. 
Profound  depression  of  a  melancholy  nature  may  alternate  with 
restlessness  and  excitement.  The  picture  may  be  complicated  by 
neuralgias,  headaches,  dizziness,  and  tinnitus  aurium.  The  metas- 
tases in  other  organs,  the  liver,  intestines  lungs,  etc.,  the  insidious 
or  the  acute  perforations  may  produce  a  variety  of  complications 
which  in  individual  cases  are  manifested  by  characteristic  symp- 
toms. Certain  occurrences  are  especially  significant  of  a  fatal  termi- 
nation. Among  these  is  fever,  wdiich  is  neither  a  marked  nor  a 
constant  symptom,  yet  by  no  means  as  rare  as  is  commonly  sup- 
posed. Its  course  is  irregular,  ranging  usually  between  38°  and 
39°  C.  [100-4°  and  102-2°  Fahr.],  rarely  reaching  40°  [104°  Falir.], 
and  may,  as  I  saw  in  one  case,  assume  a  purely  hectic  character. 
At  times  absolutely  or  almost  afebrile  periods  may  alternate  with 
such  high  febrile  movements  as  can  only  arise  from  secondary  in- 


FEVEEl— TERMINAL  SYMPTOMS.  181 

fiammations.  In  addition,  I  see  that  Hainpeln,*  in  a  very  interesting 
paper  on  the  symptoms  of  obscure  visceral  carcinomas,  lias  very  ac- 
curately described  two  cases  of  gastric  cancer  with  an  intermitting 
fever,  which  was  so  marked  that  chills  followed  by  fever  and  sweat- 
ing were  present,  and  the  possibility  of  the  existence  of  malaria  had 
to  be  carefully  considered. 

An  interesting  case  of  the  latter  variety  recently  came  under  my 
observation  at  the  Augusta  Hospital. 

A  man  forty-seven  years  old  was  admitted  Decem.ber  6,  1888.  Present 
illness  began  about  two  years  ago  with  symptoms  of  dyspepsia.  In  Sep- 
tember, 1888,  had  haematemesis  and  also  passed  blood  per  anum.  He  was 
treated  in  the  hospital  dixring  October  for  ''  ulcer  of  the  stomach,"  and 
was  discharged  improved.  On  December  3d,  violent  vomiting,  but  no 
haematemesis. 

On  admission  he  was  j)]aced  on  a  milk  diet,  it  being  supposed  that  a 
gastric  ulcer  was  present.  An  irregular  fever  with  evening  exacerbations 
to  39*6°  C.  [103 "3°  Fahr.]  soon  manifested  itself.  The  pains  in  the  epigas- 
trium continued,  and  became  variable  in  their  situation,  being  sometimes 
more  marked  to  the  left,  sometimes  to  the  right.  The  stomach-contents 
contained  no  free  hydrochloric  acid.  The  patient  became  more  and  more 
emaciated,  so  that  finally  a  small  tumor  could  be  palpated  in  the  right 
hypochondrium  near  the  border  of  the  liver.  Icterus  was  not  present. 
A  diagnosis  of  cancer  of  the  stomach  and  liver  was  made.  On  January 
5,  1889,  he  had  a  marked  chill,  which  recurred  several  times  ;  the  pains 
in  the  epigastrium  increased,  and  from  now  on  to  the  patient's  death 
on  February  20.  1889,  the  fever  remained  continuous,  and  a  delicate  fric- 
tion sound  could  be  heard  near  the  edge  of  the  liver.  A  diagnosis  was 
made  of  perforation  of  an  ulcerated  cancer  following  an  adhesive  in- 
flammation and  agglutination  of  the  adjacent  tissues,  and  also  a  localized 
peritonitis.  The  autopsy  revealed  the  presence  of  an  ulcerated  carci- 
noma about  the  size  of  an  apple,  which  was  situated  on  the  lesser  curva- 
ture, and  which  reached  to  and  was  adherent  to  the  diaphragm.  The 
surface  of  the  liver  was  studded  with  numerous  slightly  elevated  white 
nodules,  all  of  which  showed  recent  adhesions  to  the  parietal  peritoneum. 

Among  the  terminal  symptoms  belong  dropsical  swellings  and 
effusions  into  the  serous  cavities  ;  inflammatory  processes  may  also 
occur  in  the  lungs,  pleurse,  and  kidneys.  As  death  approaches,  de- 
lirium may  occasionally  be  present ;  this  is  to  be  regarded  as  a  de- 
lirium due  to  inanition.  Death  is  due  to  marasmus ;  the  agony  is 
brief.     Consciousness  remains  clear  for  a  long  time,  yet  disappears 

*  P.  Hampeln.  Zur  Symptomatologie  oceulter  visceraler  Careinorae.  Zeitschr. 
fill-  klin.  Medicin,  Bd.  8,  S.  233. 


182  DISEASES  OF  THE  STOMACH. 

as  death  approaclies,  so  that  a  conscious  death-struggle  does   not 
occur."^ 

As  a  rule,  the  course  of  cancer  is  progressive,  irresistible,  and  ad- 
vancing toward  a  fatal  termination.  Occasionally,  longer  or  shorter 
periods  may  occur  in  Mdiich  the  process  seems  to  stand  still,  in  fact 
even  to  retrograde.  Such  occurrences  may  lead  to  diagnostic  errors 
and  doubts.  A  very  striking  example  of  this  occurred  to  me  at  the 
beginning  of  my  practice. 

The  patient,  a  gentleman  sixty-two  years  old,  became  ill  very  gradu- 
ally with  symptoms  which  rendered  a  diagnosis  of  gastric  carcinoma  prob- 
able, but  it  could  not  be  made  absolutely.  The  patient  felt  worse  and 
became  weaker  ;  he  vomited,  had  severe  pains  in  the  region  of  the  stom- 
ach, especially  on  pressure  ;  absolute  anorexia  and  obstinate  constipation. 
A  medical  charlatan  diagnosed  the  case  as  an  affection  of  the  spleen,  and 
prescribed  rhubarb  wine  and  gruel  with  stewed  prunes  !  But — the  patient 
improved,  and,  as  I  heard  later,  ate  his  gruel  with  great  relish  ;  he  even 
went  out  again,  and  swore  by  his  doctor.  This  went  on  for  about  two 
months ;  then  the  old  symptoms  returned,  and  the  patient  became  maraslic 
quite  rapidly  and  died.  I  saw  him  again  a  short  time  before  his  death, 
and  could  then  positively  demonstrate  a  tumor  at  the  pylorus,  which  was 
about  the  size  of  a  fist. 

Such  periods  of  apparent  improvement  I  have  repeatedly  ob- 
served. Most  experienced  physicians  know  of  them  ;  they  certainly 
occur  much  more  frequently  than  the  text-books  would  lead  us  to 
suppose. 

The  duration  of  the  disease  may  vary  from  between  three  to 
six  months  to  two,  three,  or  more  years ;  on  an  average  it  lasts  be- 
tween six  and  fifteen  months  ;  a  shorter  course  is  at  all  events  ex- 
ceptional. It  always  terminates  fatally :  cases  of  cured  cancer  of 
the  stomach  have  been  repeatedly  reported,  yet  they  have  never 
been  positively  proved.  The  cases  reported  by  Dittrich,  Lebert, 
Friedreich,  and  others,  may  have  been  mistaken  for  gastric  ulcers 
or  the  superficial  cicatrices  which  have  already  been  described. 
Thus,  in  one  of  my  cases  of  cancer  of  the  breast,  I  found  in  the 
stomach  a  radiating  cicatrix  with  thick,  callous  edges  and  a  marked 
atrophy  of  the  mucous  membrane  in  the  vicinity.     It  would  have 


*  [Dyspnoeic  coma,  as  in  diabetes,  may  also  occur  in  the  latter  stages  of  gastric 
cancer.  Gerhardt's  reaction  may  or  may  not  be  present  in  the  urine.  See  Welch, 
loG.  cit.,  pp.  534  et  seq.  Tb.] 


OCCURRENCE   OP   VARIOUS  SYMPTOMS.  183 

been  reasonable  to  suppose  that  this  was  a  healed  primary  carci- 
noma of  the  stomach  Avith  metastases  in  the  mammary  gland.  But 
the  microscope  showed  just  the  reverse.  The  base  of  the  scar 
was  formed  by  firm,  dense  connective  tissue,  while  in  the  imme- 
diate vicinity  of  the  border  in  the  submucosa  scattered  cell-nests 
were  found ;  these  could  only  be  regarded  as  the  beginning  of  a 
cancerous  process.  The  process  was  thus  a  cancer  which  had  de- 
veloped in  the  cicatrix  left  after  the  healing  of  an  ulcer  {vide  Ulcer 
of  the  Stomach).  The  opinion  that  this  was  a  cicatrized  carcinoma 
was  also  excluded,  because  such  an  abrupt  transition  from  purely 
fibrous  tissue  to  recent  carcinomatous  proliferation  as  was  present  in 
this  case  is  never  found  in  a  cancerous  cicatrix. 

The  above  clinical  picture  is  only  schematic,  and  in  an  individ- 
ual case  numerous  modifications  may  occur.  Writers  have  taken 
great  pains  to  determine  the  relative  frequency  of  the  occurrence  of 
the  various  symptoms,  and  in  the  works  of  Brinton  and  Lebert  you 
will  find  analyses  carefully  prepared  from  relatively  large  numbers 
of  cases.  In  practice,  i.  e.,  in  the  diagnosis  of  a  suspected  case,  such 
statistics  have  only  a  relative  value,  and  are  more  interesting  for 
the  nosology  of  the  disease.  If  we  remember  our  statistics  never 
so  well,  who  will  guarantee  that  a  given  case  is  the  rule  or  an  ex- 
ception ? 

To  illustrate  the  above,  I  present  the  accompanying  half-sche- 
matic drawing  (Fig.  22)  of  a  case  in  which  a  colloid  cancer  involved 
the  lesser  curvature,  and,  being  partially  covered  by  the  left  lobe 
of  the  liver,  could  not  be  palpated  during  life.  The  jjatient  was  a 
tailor,  forty- eight  years  old,  who  had  never  complained  of  pain,  and 
had  never  had  hsematemesis.  A  probable  diagnosis  of  cancer  of 
the  stomach  had  been  made  at  the  clinic  of  Prof.  Frerichs,  solely 
upon  the  marked  anorexia  and  the  progressive  cachexia,  and  by  the 
careful  exclusion  of  other  diseases.  The  fact  that  hsematemesis 
occurs  in  42  per  cent  (according  to  Lebert,  in  only  12  per  cent)  of 
the  cases,  and  that  a  tumor  is  absent  in  20  per  cent,  would  have  de- 
cided this  case  neither  positively  nor  negatively. 

For  the  sake  of  completeness,  however,  and  because  it  may  nev- 
ertheless be  of  some  assistance,  I  shall  not  withhold  the  following 
^figures.     They  are  based  upon  an  analysis  of  250  cases  reported 


184 


DISEASES  OF   THE  STOMACH. 


Fig.  22. — Mr.  E.,  died  March  17, 1874.     Colloid  cancer  of  lesser  curvature  of  stomach. 


OCCURRENCE  OP  VARIOUS  SYMPTOMS,  185 

bj  Brintoii  and  88  and  145  cases  respectively  collected  by  Le- 
bert.* 

Loss  of  appetite  occurs  in  45  per  cent ;  often  is  observed  only 
toward  the  close  of  the  disease ;  rarely  the  appetite  is  increased 

Pain  is  present  in  92  per  cent  (Lebert,  75  per  cent).  It  is  fre- 
quently absent  in  old  people.  Brinton  claims  that  pain  between  the 
scapulae  indicates  a  cancer  on  the  lesser  curvature.  In  the  case 
which  I  have  just  cited  there  was  no  reference  to  such  an  interscap- 
ular pain,  and  my  own  experience  leads  me  to  consider  that  the  sig- 
nificance of  this  symptom  has  been  exaggerated. 

Vomiting  occurs  in  88  per  cent  (Lebert,  80  per  cent).  It  is 
most  frequent  where  the  orifices  are  involved,  l^evertheless,  a 
marked  stenosis  of  the  pylorus  may  exist  without  the  occurrence 
of  vomiting.  While  in  most  cases  it  occurs  a  considerable  time 
after  the  meal  (one,  two,  or  three  hours),  yet  it  may  take  place 
much  sooner,  and  in  drunkards  and  very  debilitated  persons  may 
even  be  present  in  the  morning  when  the  stomach  is  empty.  There 
is  thus  nothing  typical  in  the  time  of  its  occurrence. 

IIcBinatemesis  is  noted  in  42  per  cent  of  Brinton's  cases.  Lebert 
distinguishes  large  haemorrhages  from  the  stomach  from  true  me- 
Isena  or  melanemesis  [the  vomiting  of  black  altered  blood]  ;  the  fre- 
quency of  the  former  he  estimates  at  only  12  per  cent. 

A  tumor  is  present  in  80  per  cent  of  the  cases,  according  to 
both  Brinton  and  Lebert.  It  is  seldom  palpable  before  the  third  to 
the  sixth  month ;  usually  it  is  only  distinct  in  the  second  half  of 
the  course  of  the  disease,  or  during  the  last  months  of  the  patient's 
life. 

The  howels  remain  regular  in  only  4  to  5  per  cent  of  the  cases. 
In  the  vast  majority  there  is  constipation,  or  constipation  alternat- 
ing with  diarrhoea ;  the  latter  is  a  manifestation  of  a  catarrhal  con- 
dition of  the  intestinal  mucous  membrane,  due  to  the  irritation  of 
hard  fecal  masses,  or  of  products  of  decomposition  which  have 
not  been  carried  off.  A  gastro-intestinal  fistula  may  be  formed, 
and   faeces   and  gases  may  reach  the  stomach,   or  the  stools  may 

*  A  Ott  (Zur  Pathologie  des  Magenearcinoms,  Inatig.  Dissert.,  Zurich,  1867) 
has  added  33  additional  cases  from  Prof.  Biermer's  clinic,  and  has  obtained  sub- 
stantially the  same  results, 


13g  DISEASES  OF  THE  STOMACH. 

become  lienteric  (i.  e.,  tlie  presence  of  undigested  food  in  tlie 
fgeces).  Yet  Eampold*  has  observed  a  commnnication  between 
the  stomach  and  transverse  colon  and  an  adjacent  loop  of  intestine 
in  a  patient  sixty-six  years  of  age,  who  gave  no  definite  symptoms 
indicating  a  gastric  lesion ;  it  mnst  be  noted,  however,  that  the 
patient  also  suffered  from  dementia  paralytica.  Mnrchison  f  has 
called  attention  to  the  fact  that  stercoraceons  vomiting  will  be 
absent  when  the  contents  of  the  stomach  pass  directly  into  the 
colon,  since  there  can  be  no  formation  of  faeces.  Finally,  we  mnst 
mention  one  peculiarity  wliich  is  observed  where  the  orifices  of  the 
stomach  are  involved  by  the  cancer — i.  e.,  the  breaking  down  of 
the  new  tissue  may  cause  the  symptoms  due  to  the  stenosis  to  dis- 
appear, and  thus,  at  times,  an  improvement  may  seem  to  have 
occurred. 

The  condition  of  the  Mood  deserves  especial  notice.  Laache  % 
describes  a  lessening  of  the  number  of  the  red  blood-cells  in  this 
disease ;  Lepine  *  calls  attention  to  the  temporary  occurrence  of 
numerous  microcytes,  whose  number  may  be  estimated  at  one  half 
that  of  the  red  blood-cells.  Eisenlohr  ||  and  Schneider,  ^  besides 
the  above  changes,  observed  a  relative  and  even  an  absolute  in- 
crease in  the  number  of  white  blood-cells,  so  that  the  condition  of 
the  blood  may  resemble  that  of  pernicious  ansemia,  or  even  of 
leucocytha^mia ;  Schneider  also  says  that  "  these  so  easily  recognized 
changes  in  the  blood  may  become  a  not  unimportant  item  in  the 
differential  diagnosis." 

Diagnosis. — Although,  taking  all  in  all,  the  diagnosis  of  the 
disease  may  be  made  from  what  has  already  been  stated  concerning 
the  development,  course,  and  general  symptomatology,  yet  there 
still  remain  certain  important  diagnostic  features,  the  considera- 
tion of  which  I  must  not  omit.     I  shall  begin  with  the  one  which 


*  Rampold.     Hufeland's  Journal,  5.  Stiick,  1830. 

f  Quoted  by  Henoch.     Klinik  der  Unteiieibskrankheiten.     Berlin,  18G3. 
X  S.  Laache.     Die  Anaemie.     Christiania,  1883. 

*  Lepine  et  Germont.     Note,  etc.     Gazette  med.  de  Paris,  1877,  No.  14. 

II  Eisenlohr.  Blut  und  Knochenmark.  Deutsches  Archiv  fiir  klin.  Med.,  Bd. 
80.  S.  495. 

^  G.  Schneider.  Ueber  die  morphologichen  Vehaltnisse  des  Blutes  bei  Herz- 
krankheiten  und  bei  Carcinoin.     Inaug.  Diss.     Berlin,  1888. 


ABSENCE  OP  HYDROCHLORIC  ACID.  187 

is  of  most  recent  origin,  and  which  has  given  rise  to  somewhat  too 
precipitate  and  exaggerated  hopes.     I  refer  to — 

1.  The  absence  of  free  hydrocliloric  acid  in  the  stomach-con- 
tents. It  was  a  great  triumph  of  Prof.  Kussmaiil's  chnic  to  have 
first  methodically  investigated  the  subject.  The  ojjinion  was  origi- 
nally expressed  by  E,.  von  den  Velden,  that  cancer  of  the  pylorus, 
accompanied  by  dilatation  of  the  stomach,  leads  to  a  suppression 
of  the  secretion  of  hydrochloric  acid.  This  view  was  soon  indis 
criminately  applied  to  all  varieties  of  cancers  of  the  stomach.  But 
even  the  combined  labors  of  numerous  investigators,  and  not  the 
least,  of  the  above-mentioned  clinic,  have  shown  that  this  statement 
can  not  be  maintained  in  its  entirety ;  yet  it  has  led  to  results  of 
great  diagnostic  and  therapeutic  significance. 

But  historical  justice  demands  that  we  think  of  an  investigator 
who,  years  ago,  so  thoroughly  studied  the  question  of  the  occurrence 
of  hydrochloric  acid  in  gastric  cancer  that  the  knowledge  of  his 
conclusions  would  have  spared  us  much  needless  discussion.  Re- 
markably, however,  his  labors,  splendid  for  the  age  in  which  he 
lived,  have  so  absolutely  passed  into  oblivion  that  even  his  own 
countrymen  nowhere  speak  of  them.  Golding  Bird,  Physician  to 
the  Islington  Dispensary,  and  Professor  of  Medicine  at  Guy's  Hos- 
pital in  London,  in  1842,*  in  a  man  forty-two  years  old,  with  pyloric 
cancer  and  dilatation  (verified  by  autopsy),  determined  the  relation 
of  hydrochloric  and  the  organic  acids  in  a  series  of  examinations 
of  the  vomit,  the  methods  employed  being  faultless  even  to-day.f 
In  about  three  weeks  three  estimations  were  made,  the  results  of 
which  led  Bird  to  conclude  that,  "  during  the  more  irritative  stage 
of  the  disease,  free  hydrochloric  acid  is  present  in  the  vomit  in  con- 
siderable quantities,  but  it  gradually  diminishes  in  proportion  to  the 
patient's  loss  of  strength  ;  and  that  the  organic  acids  increase  pro- 
portionally as  the  free  hydrochloric  acid  diminishes."  It  is  worthy 
of  note  that,  by  a  control-experiment  on  a  healthy  subject  (an  emetic 


*  Golding  Bird.  Contributions  to  the  Chemical  Pathology  of  some  Forms  of 
Morbid  Digestion.     London  Med.  Oazette,  1843,  vol.  ii,  p.  39L 

f  Distillation  of  the  volatile  acids,  incineration  of  the  residue,  boiling  with 
dilute  nitric  acid,  and  estimating  the  silver  salt  with  and  without  the  addition  of 
soda. 


188  DISEASES  OF  THE  STOMACH. 

dose  of  sulphate  of  zinc  was  given  thirty  minutes  after  a  moderate 
dinner),  free  hydrochloric  acid,  but  only  a  very  small  quantity  of 
organic  acids,  could  be  demonstrated ;  another  experiment,  on  a 
patient  with  cancer  of  the  liver  and  dilatation  of  the  stomach 
resulting  from  pressure  of  the  tumor  on  the  pylorus  showed  a  some- 
what lessened  amount  of  free  hydrochloric  acid  but  large  amounts 
of  combined  hydrochloric  and  organic  acids. 

In  these  investigations  it  may  be  possible  that  a  little  confu- 
sion may  exist  in  the  relation  of  the  free  to  the  combined  hydro- 
chloric acid  and  the  organic  acids,  because  the  diet  and  the  time  of 
the  emesis  were  not  precisely  determined  ;  yet  Bird's  deductions  are 
not  to  be  questioned,  and  are  of  great  importance.  Bird  himself 
was  conscious  of  this,  but  complains  of  the  amount  of  time  de- 
manded by  these  studies,  and  it  seems  he  did  not  pursue  them 
further.  In  this  way  they  passed  into  obscurity,  and  it  was  only 
recently  that  this  subject  was  again  taken  up,  but  with  new  meth- 
ods. 

The  subject  has  been  and  is  still  being  investigated  by  a  daily 
increasing  array  of  clinicians  and  physicians.  To  show  you  the  ex- 
tent of  this  discussion  I  need  merely  mention  in  chronological  order 
the  names  of  von  den  Yelden,  Ewald,  Kietz,  Thiersch,  Eiegel,  Kahn 
and  von  Mehring,  Jaworski  and  Gluczynski,  Bamberger,  Kraus, 
Dreschfeld,  Eosenbach,  Krukenberg,  Eosenheim,  and  many  others. 
Unquestionably  the  largest  amount  of  material  was  collected  by 
Eiegel,  who  recently  reported  sixteen  cases  of  cancer  of  the  stomach, 
in  which  three  hundred  and  six  separate  examinations  were  made.* 
It  will  be  superfluous  to  follow  the  views  expressed  pro  and  con  by 
the  various  writers,  especially  since  it  seems  to  me  that  a  definite 
decision  has  been  or  soon  will  be  reached.  For  the  question  has 
been  much  simplified  since  all  have  finally  agreed  as  to  what  is  to 
be  understood  by  the  absence  of  free  hydrochloric  acid — i.  e.,  the 
results  either  of  the  color  tests  described  in  the  first  lecture,  or  of 
careful  chemical  analyses.  It  is  apparent  that  the  practical  impor- 
tance of  the  former  tests,  in  so  far  as  they  give  a  uniform  result,  is 
not  diminished  by  theoretical  considerations  based  upon  the  latter. 


*  Loc.  cit.,  p.  430. 


ABSENCE   OF  HYDROCHLORIC  ACID.  189 

It  can  very  well  be  maintained,  as  I  have  always  done,  that  carcinoma 
reo-arded  as  a  histological  neoplasm,  in  no  way  lessens  or  destroys 
the  secretion  of  hydrochloric  acid.  This  has  recently  received  addi- 
tional and  almost  superfluous  corroboration  by  the  unearthing  of 
Bird's  researches.  But,  whatever  view  is  taken,  it  would  neverthe- 
less be  a  valuable  diagnostic  criterion,  provided  other  complicating 
factors  did  not  interfere  with  the  determination  of  the  presence  of 
hydrochloric  acid — but  not  of  its  secretion.  Each  is  correct.  "When 
the  new  growth  is  confined  microscopically  and  macroscopically 
(which  by  no  means  always  correspond)  to  a  limited  area,  when  the 
accompanying  catarrh  of  the  mucous  membrane  is  moderate,  and 
when  there  is  no  atrophy,  then  the  secretion  of  hydrochloric  acid 
may  remain  ample  till  it  disappears  with  the  approach  of  death ;  or 
it  may  be  much  diminished,  as  occurs  in  all  cachectic  conditions. 
However,  in  the  vast  majority  of  cases  one  of  the  above-mentioned 
factors  plays  a  prominent  part,  and  the  secretion  of  hydrochloric 
acid  is  either  entirely  annihilated  or  is  reduced  to  so  small  a  quan- 
tity as  not  to  be  demonstrable  with  the  ordinary  tests.  This  would 
afford  us  an  exceedingly  good  diagnostic  criterion  but  for  the  fact — 
be  it  said  with  regret — that  a  diminution  in  this  secretion  may  occur 
in  other  pathological  conditions  of  the  gastric  mucosa.  These  in- 
clude atrophy  and  amyloid  degeneration  of  the  membrane ;  self- 
evidently,  poisoning  or  corrosion,  in  which  a  large  portion  of  the 
mucous  lining  is  destroyed ;  mucous  catarrhs  and  certain  neuroses 
depending  upon  or  associated  with  a  disturbance  of  the  innervation 
of  the  gastric  glands.  It  is  manifest,  as  I  have  already  stated,  that 
acute  injuries  of  the  gastric  mucosa,  poisoning,  and  acute  indigestion 
may  cause  a  loss  of  glandular  activity,  just  as  in  an  acute  catarrh  of 
the  kidney  there  is  a  marked  diminution  of  its  secretion,  or  as  an 
injection  of  atropine  into  Wharton's  duct  dries  up  the  salivary  secre- 
tion. Likewise,  in  my  own  person  I  found  that  the  stomach-con- 
tents were  absolutely  free  from  hydrochloric  acid  during  a  very 
transitory  nicotine  poisoning ;  on  another  occasion,  during  a  sea- 
voyage,  I  could  obtain  no  reaction  with  Congo  paper  in  the  food 
which  was  vomited  one  hour  after  breakfast.  Such  conditions  are 
only  of  short  duration,  and  rapidly  disappear  after  the  removal  of 
the  irritant  or  under  a  suitable  diet.     The  experiments  of  Wolf- 


190  DISEASES  OP  THE  STOMACH. 

ram  *  show  that,  while  fever  is  present  in  all  the  acute  infections 
diseases,  the  gastric  juice  contains  no  hydrochloric  acid  and  exerts 
no  digestive  action  either  within  or  outside  of  the  organism. 
We  also  know  concerning  certain  chronic  diseases — for  example, 
Addison's  disease  (Kohler),  pernicious  ansaemia,  many  cases  of  pul- 
monary phthisis  (C.  Rosenthal) — that  the  secretion  of  hydrochloric 
acid  is  reduced  to  a  minimum,  and  no  free  acid  can  any  longer  be 
detected. 

But  even  physiologically  there  are  very  marked  variations  in  the 
amount  of  acid  produced  ;  the  free  acid  depends  essentially  upon 
the  quantity  of  albumen  which  is  converted  into  acid  albumen  or 
peptones,  which  absorb  the  HCl  or  form  loose  combinations  with  it. 
Thus  free  acid  may  be  present  or  absent  in  the  gastric  juice  after 
eating  the  same  food,  but  with  varying  conditions  of  secretory  activ- 
ity. We  must,  therefore,  heartily  agree  with  Eiegel  when  he  de- 
mands that  a  positive  opinion  should  only  be  expressed  after  exami- 
nations which  have  been  conducted  a  long  time,  and  with  the  aid  of 
a  suitable  therapy.  JSTormally,  the  production  and  secretion  of  tlie 
hydrochloric  acid  are  so  regulated  according  to  the  demands  of  the 
ingesta  that  free  acid  is  immediately  present  in  sufficient  quantity 
to  give  a  distinct  reaction  with  the  color-tests,  etc.  This  does  not 
occur  in  the  vast  majority  of  cases  of  cancer  of  the  stomach.  But 
this  does  not  depend  upon  some  influence  of  the  cancer  on  the  pro- 
duction of  HCl,  but  is  simply  due  to  the  accompanying  catarrhal, 
inflammatory,  or  atrophic  conditions  of  the  gastric  mucous  mem- 
brane. If  these  are  absent  the  acid  is  secreted  abundantly,  as  in  the 
case  reported  by  Bird,  another  by  Calm,  and  still  another  reported 
later  which  had  been  observed  by  von  den  Yelden.f  But  if,  during 
our  observation  of  such  a  patient,  one  of  the  above  processes  in- 
volves the  gastric  mucous  membrane  and  becomes  more  marked,  or 
if  the  organism  gradually  becomes  weaker  and  weaker,  and  if  with 
this  the  functions  of  the  organ  primarily  involved  naturally  give  way 
first,  then  the  transition  from  the  occurrence  of  hydrochloric  acid  to 

*  Announced  by  Gluczynski.  Ueber  das  Verhalten  des  Magensaftes  in  fieber- 
haften  Krankheiten.     Deutsches  Arch,  fiir  klin.  Med.,  Bd.  33. 

f  Cahn.  Verhandlungen  des  YI.  Congress,  fur  innere  Medicin,  1887,  S.  362 
und  373. 


ABSENCE   OP  HYDROCELORIC   ACID.  191 

its  absence  may  take  place  in  a  relatively  sliort  space  of  time.  In 
this  way  I  explain  Bird's  case,  and  also  one  which  came  under  my 
own  observation. 

Mr.  R.,  merchant,  forty -two  years  old,  was  seen  in  consultation  on 
January  7th.  He  had  suffered  for  a  long  time  from  "  chronic  catarrh,'' 
and  had  complained  of  a  severe  burning  sensation  in  the  stomach  for 
several  months.  He  was  admitted  to  the  Augusta  Hospital,  and  while 
there  was  treated  with  the  stomach-tube  and  was  very  much  benefited  by 
it.  He  learned  to  wash  out  his  stomach  and  did  it  frequently,  especially 
as  he  sought  in  this  way  to  remedy  his  frequent  dietetic  errors. 

The  patient  was  a  haggard  man,  with  a  dry  skin  and  retracted  abdo- 
men ;  he  lay  in  bed  on  account  of  weakness.  Heart  and  lungs  negative. 
There  was  a  small  movable  tumor  at  the  pylorus  about  the  size  of  a  wal- 
nut, slightly  tender  on  pressure.  No  succussion  sound.  The  stomach 
when  distended  reached  to  the  umbilicus,  causing  the  tumor  to  move 
downward  and  somewhat  to  the  right.  During  the  introduction  of  the 
tube  by  himself  he  vomited  slimy,  yellowish-green,  c>ffensive  masses  of 
neutral  reaction  ;  accordingly,  no  free  acid  was  present.  No  glandular 
swellings.     Urine  clear  and  acid.     Stools  irregular. 

The  stomach-contents,  after  taking  the  test-breakfast  on  the  following 
morning,  undoubtedly  contained  a  considerable  amount  of  hydrochloric 
acid  and  small  quantities  of  lactic  acid,  peptone,  and  propeptone.  The 
stomach-contents  digest  slowly. 

In  view  of  the  presence  of  hydrochloric  acid,  a  diagnosis  was  made 
of  a  non  -  carcinomatous  hypertrophy  of  the  pylorus  (cicatrization  of 
an  old  ulcer  ;  muscular  hypertrophy  accompanying  a  chronic  ca- 
tarrh (?) ). 

But  on  the  following  day  the  iiatient  vomited  bloody  masses  and  com- 
plained of  severe  burning  pain  in  the  stomach,  and  an  almost  intolerable 
dryness  of  the  mouth,  pharynx,  and  oesophagus.  Vomiting  recurred  very 
frequently  during  the  next  three  weeks  in  spite  of  a  rigorous  diet  and 
regular  lavage  of  the  stomach.  Each  time  the  stomach -contents  were 
abundant,  of  a  bloody  color,  or  contained  broken-down  coagula  ;  frag- 
ments of  food  were  also  present.  Hydrochloric  acid  was  never  found  ; 
on  the  other  hand,  large  quantities  of  yeast-cells,  bacteria,  and  mucus 
could  be  seen.  The  reaction  was  usually  neutral  ;  if  acid,  it  was  due  to 
acid  salts  or  lactic  acid.  On  two  different  occasions  the  test-breakfast  was 
given  lege  artis,  and  each  time  the  absence  of  hydrochloric  acid  was 
noted.  The  tumor  remained  unchanged  and  could  be  felt  more  or  less 
distinctly,  according  to  the  fullness  of  the  stomach.  The  patient  suffered 
intensely,  lost  strength  rapidly,  and  urgently  wished  the  removal  of  the 
tumor  by  operation.  In  view  of  the  large  quantities  of  "  stomach-con- 
tents "  which  were  siphoned  through  the  tube  from  the  patient's  stom- 
ach— often  amounting  to  four  or  five  litres  [nine  to  eleven  pints]— dila- 
tation of  the  stomach  was  diagnosed,  although  a  repetition  of  the  disten- 
tion of  the  viscus  with  air  again  gave  no  positive  evidence  thereof.  I 
could  not  quite  explain  this  peculiar  condition,  but  I  expressed  to  my  col- 
leagues the  suspicion  that  the  siphoned  fluid  came  from  the  intestines 


192  DISEASES  OP  THE  STOMACH. 

rather  than  from  the  stomach,  the  fluid  having  regurgitated  into  the  latter 
through  the  rigid  and  thus  incompetent  pylorus. 

At  the  patient's  request,  Prof.  Sonnenberg  resected  the  pylorus  on  Jan- 
uary 30th— i.  e.,  about  three  weeks  after  the  first  examination.  At,  and 
sui'rounding  the  pylorus,  was  a  hard  tumor,  the  size  of  a  walnut,  which  so 
narrowed  the  orifice  that  the  tip  of  the  little  finger  could  be  inserted  only 
with  difficulty.  Several  glands  in  the  ligamentum  gastro-colicum  were 
enlarged  to  the  size  of  cherries.     The  stomach  was  not  dilated. 

After  the  operation  everything  went  smoothly  and  for  the  first  few 
days  the  patient's  condition  was  excellent.  On  the  fourth  day  there  was 
a  slight  febrile  movement,  followed  by  marked  collapse  ;  the  patient  died 
on  the  evening  of  the  fifth  day.  At  the  autopsy  I  found  that  some  of  the 
sutures  (catgut  and  silk)  had  suppurated,  causing  a  localized  purulent  and 
adhesive  peritonitis  which  may  be  regarded  as  the  cause  of  death.  The 
mucous  membrane  in  the  line  of  sutures  was  hyperaemic,  hut  elseivhere 
was  entirely  uninvolved.  On  the  other  hand,  the  muscularis  as  far  as  the 
fundus  was  infiltrated  and  thickened.  A  piece  of  the  fresh  tumor  was 
immediately  placed  in  absolute  alcohol,  which  was  subsequently  fre- 
quently changed  ;  microscopical  examination  showed  that  it  was  a  scir- 
rhus  carcinoma  which  was  almost  entirely  limited  to  the  muscularis,  in- 
filtrating it  in  broad  bands.  The  greater  part  of  the  mucous  membrane 
was  entirely  normal,  or  at  most  only  slightly  infiltrated  by  an  interstitial 
proliferation  of  small  cells  from  the  submucosa.  In  places  there  was 
more  atypical  growth  of  the  glandular  tubules,  and  cysts  of  various  sizes 
were  found  toward  and  in  the  submucosa.  On  comparing  this  section 
with  a  preparation  from  a  catarrhal  stomach  no  marked  differences 
could  be  found.  The  same  was  true  of  pieces  of  tissue  which  were  taken 
at  the  autopsy  from  the  fundal  and  cardiac  portions.  In  the  affected 
area  the  submucosa  was  sharply  defined  from  the  mucosa  on  the  one  side 
and  from  the  infiltrated  muscularis  on  the  other  ;  even  with  the  naked 
eye  its  wide-meshed  fibrous  structiu'e  could  be  I'ecognized. 

The  great  significance  of  tins  case  is  manifest.  It  proves  that 
with  a  localised  cancer  and  an  intact  mucous  inemhrane  the  secre- 
tion of  hydrochloric  acid  may  continue  up  to  a  short  thne  Ijefore 
death  I  and  xinder  such  circumstances  cortclusions  based  %ipon  the 
demonstration  of  this  acid  may  he  erroneous.  The  peculiar  features 
connected  with  the  sipbonage  of  the  stomach  are  an  additional  in- 
teresting point  of  this  case.  The  distention  of  the  stomach  with  gas 
afforded  i-eliable  data ;  and  the  large  quantities  of  fluid  which  were 
obtained  without  any  exertion  are  only  to  be  explained  as  above. 
There  was  thus  a  true  and  actual  insufficiency  of  the  pylorus,  l^ev- 
ertheless,  it  may  be  said  that  the  duodenum  could  not  be  distended. 
This  can  be  readily  understood  if  the  large  capacity  of  this  part  of 
the  intestine  be  compared  with  the  small  amount  of  air  which  can 


ABSENCE   OF   HYDROCHLORIC   ACID.  I93 

be  pumped  in.  Finally,  the  admixture  of  blood  in  tlie  stomach-con- 
tents, wliicli  was  constantly  observed  toward  tlie  close  of  life,  re- 
mains entirely  inexplicable ;  the  autopsy  afforded  no  clew ;  there- 
fore, as  in  other  cases,  we  must  assume  the  occurrence  of  gradual 
rhexis  from  the  vessels. 

Since  the  observation  of  this  case  a  number  of  careful  investiga- 
tions have  been  made  on  the  relations  of  hydrochloric  acid  to  cancer 
of  the  stomach  ;  of  these  I  shall  only  quote  the  following :  In  eight 
cases  of  this  disease  which  were  carefully  studied,  both  auatomically 
and  chemically,  Stienon  *  reports  that  four  gave  no  reaction  to  the 
color-tests,  while  the  other  four  gave  temporary,  more  or  less  posi- 
tive results.  In  fourteen  examinations  made  on  two  cases  with  the 
method  of  Cahn  and  von  Mering,  positive  reactions  were  obtained, 
the  amount  of  hydrochloric  acid  varying  between  0*4  and  2"3  per 
thousand,  but  the  color-tests  gave  a  negative  result  every  time.  The 
microscopic  examination  convinced  him  that  the  disease  is  fre- 
quently, if  not  usually,  accompanied  by  an  atrophy  of  the  glands, 
and  to  this  may  be  due  the  absence  of  hydrochloric  acid.  This  may 
be  true  of  many  but  by  no  means  of  all  the  cases  of  gastric  cancer, 
because  experience  teaches  us  that  the  accompanying  affection  of 
the  mucous  membrane  may  restrict  itself  to  a  more  or  less  extensive 
and  intense  inflammatory  process  (catarrh). 

A  very  comprehensive  study  of  this  subject  was  also  made  by 
Rosenheim  f  with  the  aid  of  Cahn  and  von  Mering's  method.  In 
fourteen  out  of  sixteen  cases  of  gastric  carcinoma  he  could  never 
demonstrate y^ee  hydrochloriG  acid  at  the  height  of  digestion ;  in 
another  it  was  present  temporarily  ;  in  still  another  it  was  not  alone 
present,  but  there  were  even  hyperacidity  and  hypersecretion.  In  re- 
gard to  the  latter  case  it  must  be  noted  that  the  color-tests  for  hydro- 
chloric acid  were  almost  always  negative,  and  that  the  statement  of 
the  presence  of  hyperacidity  is  based  upon  a  method  (Cahn  and  von 
Mering's)  which  is  not  free  from  objections.    Yet  this  is  at  present 


*  L.  Stienon.     Le  sue  gastrique  et  les  phenoraenes  chimiques  de  la  digestion  dans 
les  maladies  de  restomac.     Journal  de  Med.  de  Bruxelles,  October  5,  1888. 

f  Th.  Rosenheim.    Ueber  atrophisehe  Processe  in  der  Magenschleimhaut  in  ihrer 
Beziehung  zum   Carcinom   und   als   selbststandige   Erkrankung.      Berliner  klin. 
Wochenschr.,  1888,  No.  51-53. 
IC 


194  DISEASES  OP  THE  STOMACH. 

of  minor  interest  as  compared  with  the  unanimous  result  of  the  in- 
vestigations of  these  writers,  namely,  that  under  certain  conditions 
free  hydrochloric  acid  may  be  present  in  cancer  of  the  stomach. 

In  this  disease  the  stomach-contents,  containing  no  free  acid, 
exert  no  digestive  action,  even  on  the  addition  of  hydrochloric  acid, 
or  of  small  quantities  of  normal  chyme.  The  reason  for  this  I  gave 
long  ago  in  my  answer  to  Riegel's  experiment  upon  this  point,  i.  e., 
that  the  HCl  is  seized  by  the  excess  of  albumen,  and  hence 
does  not  come  into  action.  Had  Riegel  added  the  acid  till  free 
HCl  could  be  demonstrated,  his  trial  of  digestion  would  have 
been  successful,  since  pepsin  is  seldom  absent.  For  the  other  ingre- 
dients of  the  gastric  juice,  the  pepsin  and  rennet  are  not  lessened  to 
the  same  degree  as  the  hydrochloric  acid.  The  products  of  the  action 
of  pepsin,  the  peptones,  are  found  almost  without  exception  even 
where  neither  free  hydrochloric  nor  lactic  acid  is  present.  Hence 
pepsin  must  have  been  secreted,  and  sufficient  free  HCl  to  form 
peptone  must  have  been  present  at  some  time.  The  majority  of 
these  filtered  stomach-contents  form  not  alone  prope23tone  but  also 
true  peptone,  if  they  are  acidulated  to  about  two  per  thousand  of  free 
HCl.  Boas  {loo.  cit.)  claims  to  have  found  rennet  even  Mdiere  free 
HCl  was  absent.  The  explanation  of  this  apparent  paradox  lies  in 
the  fact  that  the  secreted  HCl  combines  with  any  free  bases,  weak 
salts  and  albumen  and  its  derivatives,  while  the  ferments  remain 
free ;  and  of  the  latter  we  know  that  their  action  only  begins  to  be 
lessened  when  the  products  of  fermentation  are  present  in  excess. 
The  relation  of  these  three  elements  [hydrochloric  acid,  pepsin,  and 
rennet],  and  the  mode  of  determining  them,  will  therefore  depend 
very  much  upon  the  nature  of  the  food  and  the  energy  of  the  secre- 
tion— the  effects  of  the  variety  and  extent  of  the  lesion  of  the  mu- 
cous membrane  being  self-evident. 

But  the  important  fact  remains  that  free  hydrochloric  acid  is 
usually  absent  in  carcinoma  of  the  stomach.  Unfortunately,  the 
diagnostic  value  of  this  circumstance  is  decidedly  affected  by  the 
occurrence  of  this  same  loss  in  the  other  conditions  which  I  have 
already  mentioned.  JBut,  granting  this,  the  proposition,  which  I 
was  the  first  to  announce,  is  still  true,  that  the  demonstration  of  the 
presence  of  hydrochloric  acid  points  with  very  great  prol)a})iliiy 


TISSUE   ELEMENTS   IN  VOMIT.  196 

against  the  existence  of  cancer  of  the  stomach  /  for  the  cases  of 
this  disease  in  whicli  there  is  a  positive  reaction  to  the  carefully 
applied  tests  are  so  rare  that  they  have  very  little  bearing  on  the 
question. 

Under  certain  conditions  (stagnation  of  the  ingesta  or  the  intro- 
duction of  easily  fermenting  food)  the  hydrochloric  acid  may  be 
replaced,  or  may  be  accompanied  by  lactic  acid,  fatty  acids  and 
their  salts,  which  may  impart  an  acid  reaction  and  penetrating 
odor  and  taste  to  the  contents  of  the  stomach.  Of  especial  interest, 
however,  is  tlie  fact,  which  has  been  repeatedly  observed  in  this 
disease,  as  well  as  in  other  affections  of  the  stomach,  that,  with  an 
absolute  loss  of  the  hydrochloric-acid  reaction,  this  deficiency  in  the 
digestive  function  has  been  replaced  for  a  long  time  by  the  vicarious 
action  of  the  intestinal  digestion,  or  by  the  formation  of  large 
quantities  of  lactic  acid  (or  eventually  of  acetic  acid). 

2.  The  presence  of  specific  tissue  elements  in  the  voinit,  or  in  the 
masses  raised  through  the  stomach-tube.  I  have  already  spoken  in 
general  of  the  constituents  of  the  vomit ;  here  I  need  only  reca- 
pitulate that  in  the  advanced  stages  of  this  malady  we  may  find  a 
very  great  variety  of  fungi,  yeast-cells,  sarcinse,  bacteria,  pavement 
and  round  epithelial  cells,  with  large  nuclei,  single  nuclei,  and  nu- 
cleoli, and  large  masses  of  detritus  colored  brown  to  a  dark  green, 
and  mixed  with  all  kinds  of  remnants  of  food.  But  the  present 
question  is.  Is  it  possible  to  recognize  specific  cancerous  tissue  ? 
This  is  certainly  impossible  with  isolated  epithelial  cells.  It  must 
be  admitted  with  regret  that,  in  spite  of  all  the  time  and  labor 
whicli  have  been  expended,  no  means  have  yet  been  discovered  by 
which  we  can  distinguish  specific  cancer-cells  from  the  ordinary 
varieties  of  epithelial  cells  found  in  the  stomach-contents,  some  of 
which  are  derived  from  the  walls  of  that  viscus,  while  others,  from 
the  mouth  and  oesophagus,  have  been  swallowed.  Even  Brinton 
said  :  "  But  mere  isolated  cells  or  nuclei  scarcely  justify  a  decision." 
Lebert,  in  his  Physiologic  pathologique.,  pictures  cells  with  six  or 
more  concentric  layers,  which  he  considers  specific  cancer-cells, 
'•''globules  cancereux  d  paroix  concentrig^ies^''  These  cells  are 
.  nothing  more  nor  less  than  starch  granules.  For  my  part,  I  only 
consider   conclusive    the   concentrically  stratified    aggregations   of 


196  DISEASES   OP   THE   STOMACH. 

cells,  true  cancer-cell  nests,  sucli  as  are  shown  in  Fig.  23,  In  the 
case  from  which  this  specimen  was  obtained  it  was  even  of  decisive 
value. 


Fig.  23. — Cancerous  cell-nest  raised  through  stomach-tube.     (From  Mr.  L.,  December  11, 
1886.     Sketched  with  camera  lucida.) 

Mr.  L.,  about  thirty -five  years  old  ;  no  inherited  diseases  ;  has  been 
complaining  for  the  last  six  months  of  anorexia,  pain  in  the  epigastrium, 
and  frequent  vomiting  ;  no  tumor  nor  cancerous  cachexia.  By  means 
of  the  stomach-tube  large  masses  of  mucus  were  obtained  every  time  ; 
hydrochloric  acid  could  never  be  demonstrated.  The  diagnosis  lay  be- 
tween a  severe  mucous  catarrhal  gastritis  and  an  occult  neoplasm.  On 
renewal  of  the  examinations  faint  blood-streaks  were  seen,  and  a  small, 
firm  particle  was  obtained  ;  from  this  the  above  preparation  was  made. 
By  its  means  alone  the  diagnosis  was  established,  and  the  death  of  the 
patient  about  two  months  later  verified  its  correctness. 

But  even  sucli  specimens  as  the  one  in  question  may  give  rise 
to  errors.  It  occasionally  happens  that  very  small  pieces  of  the  gas- 
tric mucosa  may  be  detached  where  the  membrane  is  very  vulnerable, 
even  when  a  cancerous  neoplasm  is  absent.  If  such  a  piece  is 
placed  on  a  slide,  the  pressure  of  the  cover-glass  may  cause  the 
epithelium  surrounding  an  excretory  duct  to  assume  a  concentric 
stratification  closely  resembling  a  cancerous  cell-nest.  The  drawing 
of  such  a  specimen  is  given  in  Fig.  23 ;  it,  together  with  a  large 


THE  CANCEROUS  TUMOR.  197 

shred  of  the  epithelial  lining  of  the  stomach,  was  found  in  the 
wasli-water  while  washing  the  stomach  of  a  patient  twenty-eight 
years  old,  suffering  from  a  mu- 
cous catarrhal  gastritis,  with  no 
symptoms  of  cancer,  and  whose 
improvement  was  continuous. 
Later  on,  in  the  discussion  of 
the  catarrhal  conditions  of  the 
stomach,  I  shall  be  able  to  pre- 
sent to  you  unmistakable  speci- 
mens in  totO  of  the  detached  epi-  Fig.  24.— a  piece  of  the  epithelial  covering 
,     ,.  j;  xi,        J.  1,  *^f  t^^s  mucous  membrane  of  the  stoin- 

thelmm  01  the  stomach.  ^^j^^  resembling  a   cancerous   cell-nest. 

In  three    cases    of   gastric    can-  (From  Mr.  K.,  March  10, 1887.  Sketched 

.  with  camera  lucicla.) 

cer  Kosenbach*  found  pieces  of 

the  tumor  in  the  wash-water ;  he  claims  that  even  macroscopically 
(it  is  surprising  that  no  microscopical  examination  was  made)  they 
may  be  differentiated  from  detached  portions  of  the  mucosa  by 
characteristic  punctate  haemorrhages  penetrating  into  the  tissue,  and 
by  the  old  brownish-black  blood.  I  myself  have  never  observed 
such  specimens,  and,  in  spite  of  Eosenbach's  assertions  to  the  con- 
trary, I  would  consider  them  rare,  and  as  being  entirely  dependent 
upon  the  nature  of  the  neoplasm. 

3.  The  cancerous  tumor.  Concerning  the  character  of  tumors 
in  the  stomach,  and  the  peculiarities  of  the  diagnosis  of  them,  I 
shall  only  remark,  in  passing,  that  it  is  self-evident  that  to  be  pal- 
pable they  must  be  situated  upon  the  greater  curvature,  or  at  the 
pylorus,  and  that  neoplasms  situated  upon  the  lesser  curvature  are 
beyond  the  reach  of  the  palpating  fingers,  especially  if  the  growth 
is  along  the  surface  and  is  overlapped  by  the  liver ;  such  a  condi- 
tion was  present  in  the  case  from  which  Fig.  22  was  taken ;  and, 
finally,  that  tumors  on  the  lesser  curvature  can  only  be  palpated 
when  the  stomach  occupies  an  abnormal  position.  It  is  equally 
obvious  that  the  palpation  of  stomach  tumors  may  be  rendered 
impossible  by  the  development  of  ascites  or  cancerous  peritonitis. 

*  0.  Rosenbach.  Ueber  die  Anwesenheit  von  Gesehwulstpartickelschen  in  dem 
durch  die  Magenpumpe  entleerten  Mageninhalt  bei  Carcinoma  ventriculi.  Deutsclie 
med.  Wochenschr.,  1882,  No.  33. 


198  DISEASES  OP   THE   STOMACH. 

For  a  long  time  it  was  considered  an  irrefutable  axiom  that  move- 
ment of  gastric  tmnors  with  respiration  became  possible  only  after 
adhesions  had  been  contracted  with  the  liver.  But  even  this  rule  is 
not  without  exceptions.  At  a  recent  meeting  of  the  Gesellschaft  der 
CharitS-Aerzte  zu  Berlin,  Fr.  Miiller  exhibited  a  stomach  totally 
involved  by  a  carcinoma,  without  any  adhesions  to  the  neighboring 
viscera,  and  yet  which,  during  life,  descended  with  every  inspi- 
ration, as  a  result  of  the  flattening  of  the  diaphragm.  A  similar 
movement  of  the  tumor  may  be  transmitted  from  the  liver  when 
the  neoplasm  lies  close  to  the  edge  of  the  liver  without  the  forma- 
tion of  any  adhesions.  At  the  Policlinic  I  have  repeatedly  and  care- 
fully examined  a  patient  with  such  a  tumor,  the  size  of  a  fist, 
situated  on  the  greater  curvature  near  the  pylorus ;  it  was  freely 
movable  both  with  the  fingers  and  by  distending  the  stomach  with 
air ;  the  descent  with  every  movement  of  inspiration  was  very 
noticeable.  But  such  cases  are  always  exceptional ;  and,  indeed, 
their  occurrence  as  such  merely  serves  to  strengthen  the  general 
rule  above  stated. 

It  is  also  important  to  bear  in  mind  that  most  tumors  feel  much 
larger  to  the  palpating  finger  than  they  really  are,  and  that  they 
may  change  their  position  according  to  the  fullness  of  the  stomach 
or  intestines.  In  like  manner  a  good  idea  of  the  size  and  situation, 
whether  in  the  stomach  or  in  one  of  the  adjacent  viscera,  is  not  sel- 
dom only  obtainable  after  the  distention  of  the  stomach  or  intes- 
tines. To  distinguish  a  deformity  on  the  lower  border  of  the  liver, 
especially  in  the  left  lobe,  such  as  frequently  result  from  tight  lacing 
in  women,  or  a  true  tumor  of  the  liver,  pancreas,  or  spleen  from  a 
new  growth  in  the  stomach,  may  at  times  be  very  difficult ;  at  other 
times  it  is  even  impossible.  The  reverse  may  also  occur,  and  a  car- 
cinoma of  the  stomach  may  be  regarded  as  belonging  to  the  left 
lobe  of  the  liver.  Thus  Ott,*  after  giving  a  very  careful  description 
of  such  a  case,  says  : 

"  The  complete  degeneration  of  the  entire  stomach  even  to  the  region 
of  the  liver,  the  rigid  infiltration  of  the  greater  curvature,  the  diminution 
in  size  and  contraction  of  the  organ  which  enabled  one  to  grasp  the 

*  Ott.     Zur  Pathologie  der  Magencarcinome.     Zurich,  1867,  S.  60. 


THE  CANCEROUS  TUMOE.  199 

greater  curvature,  and  which  caused  it  to  feel  like  the  edge  of  the  liver — 
all  of  these  factors  led  to  this  deception." 

It  is  equally  difficult  to  decide  wlietlier  a  thickening  at  the  py- 
lorus is  due  to  hypertrophy  of  the  muscular  coat,  cirrhosis,  foreign 
body  encapsulated  in  the  stomach,*  cicatrized  ulcer,  localized  peri- 
toneal exudate,  or  carcinoma.  Carcinomata  of  the  omentum  or  of 
the  intestines,  which  may  be  lying  alongside  of  the  stomach,  may  at 
times  be  recognized  by  a  simple  distention  of  the  gut  with  air. 
Leube  very  properly  calls  attention  to  the  possibility  of  mistaking 
the  pancreas  for  a  growing  tumor  of  the  stomach,  since  the  pro- 
gressive emaciation  of  the  patient  permits  the  pancreas  to  be  more 
easily  palpated  through  the  relaxed  abdominal  wall.  Frequently 
the  question  can  only  be  decided  after  prolonged  observation  by  the 
eventual  growth  of  the  suspected  tumor,  the  occurrence  of  cancerous 
cachexia,  the  formation  of  metastases,  and  swellings  of  the  lymph 
glands ;  but  sometimes  even  these  signs  may  fail,  and  the  autopsy 
alone  can  reveal  the  true  condition.  In  all  these  cases  the  examina- 
tion of  the  stomach-contents  is  of  great  importance.  If  the  usual 
amount  of  free  hydrochloric  acid  is  present  after  the  test-breakfast, 
we  may  say  with  tolerable  certainty  that  the  stomach  is  not  involved. 
That  this  is  not  always  true  was  shown  in  the  case  described  in  de- 
tail on  page  191.  On  the  other  hand,  I  wish  to  relate  two  cases  in 
which  this  examination  placed  the  diagnosis  beyond  doubt : 

On  November  24th  a  colleague,  Dr.  X.,  sent  to  me  Mrs.  W.,  thirty- 
three  years  old,  a  small,  emaciated  woman,  who  had  borne  four  children. 
She  complained  of  almost  continuous  pain  day  and  night  in  the  epigas- 
trium.    The  pains  were  independent  of  eating,  have  lasted  more  than  six 

*  These  foreign  bodies  which  may  simulate  malignant  tumors  are  usually  spheri- 
cal or  ovoid  agglomerations  of  hairs  which  have  been  swallowed.  But  similar 
errors  may  arise  from  "  shellac  calculus  "  {Shellackstein),  as  occurred  in  a  carpenter 
who  mistook  his  varnish  for  liquor ;  other  foreign  bodies  of  a  similar  nature  have 
given  rise  to  errors.  See  Pale'mon  Best,  Death  frona  Accumulation  of  Hair  in  the 
Stomach  of  a  Woman,  British  Medical  Journal,  December  11,  1869,  and  other  Eng- 
lish authors.  The  eating  of  hair  seems  to  be  a  favorite  occupation  of  English 
women ;  still,  unless  I  am  mistaken,  a  similar  case  was  reported  by  Schonborn. 

[Another  German  case  may  be  found  in  0.  Bollinger.  Eine  seltene  Haarge- 
schwulst  im  menschlichen  Magen.  Mlinchen.  med.  Wochenschr.,  1891,  Bd.  38,  S.  383. 
The  case  of  Schonborn,  alluded  to  above,  may  be  found  in  Arch,  fiir  klin.  Chirurg., 
Bd.  29,  S.  609  ;  the  bah  of  hair,  which  was  mistaken  for  a  movable  kidney,  was  suc- 
cessfully removed  by  operation. — Tr.] 


200,  DISEASES  OP  THE  STOMACH. 

months,  and  were  temporarily  ameliorated  by  the  use  of  Carlsbad  water. 
The  patient  belched  frequently,  but  had  a  good  appetite,  and  had  never 
vomited. 

The  tongue  was  not  coated;  the  abdomen  was  somewhat  penduloLis, 
and  its  walls  relaxed.  Close  to  and  on  the  right  of  the  median  line  was 
an  easily  movable  tumor,  which  was  painful  on  pressure;  to  the  right 
and  external  to  this  was  a  second  tumor,  smaller,  and  descending  with  in- 
spiration (gall-bladder).  Distention  of  the  stomach  with  air  revealed  a 
dilatation  and  a  descent  of  the  greater  curvature  to  midway  between  the 
symphysis  and  umbilicus.  The  stomach-contents  contained  an  abundance 
of  free  hydrochloric  acid,  but  no  products  of  fermentation  or  decomposi- 
tion. Further  questioning  revealed  that  the  patient  had  occasionally  suf- 
fered from  gastralgia.  Diagnosis:  Dilatation  of  the  stomach  resulting 
from  a  cicatricial  stenosis  of  the  pylorus,  and  hypertrophy  of  the  inuscu- 
laris  as  a  sequel  of  an  ulcer  at  this  point.  The  proof  of  this  was  the  con- 
tinuous improvement  and  gain  in  strength  after  methodical  lavage  and 
suitable  diet.     No  cancerous  cachexia  was  present. 

The  diagnosis  of  this  case  was  possible  onlj  by  knowing  the  re- 
sult of  the  examination  of  the  stomach-contents ;  and,  having  ascer- 
tained this,  it  was  rendered  sufficiently  certain.  It  is  well  known 
that  a  hypertrophy  of  the  musciilaris  in  the  pyloric  region  may 
absolutely  simulate  a  neoplasm ;  as  examples,  I  refer  to  the  case  re- 
ported by  Virchow,*  and  to  another  published  by  myself :  f 

The  latter  case  was  as  follows:  H.  S.,  fifty-six  years  old,  teacher  from 
Salzwedel.  The  man,  of  a  very  large  and  powerful  frame,  was  much  ema- 
ciated and  cachectic.  The  abdomen  was  relaxed  and  very  flaccid,  as  in  a 
multipara.  In  the  umbilical  region  close  to  the  surface  could  be  felt  a 
bi'oad,  flat,  slightly  nodular  tumor,  which  reached  on  the  right  to  the  axil 
lary  line  and  on  the  left  to  the  parasternal  line.  Deep  inspiration  gave 
rise  to  a  feeling  of  false  movement — i.  e.,  the  sliding  of  the  abdominal 
wall  simulated  the  movement  of  a  tumor.  The  patient  was  very  dyspep- 
tic, suffered  severely  from  belching,  and  vomited  occasionally.  It  was 
self-evident  that  there  was  a  carcinoma  of  the  omentum ;  the  only  ques- 
tion in  doubt  was  whether  there  was  also  a  cancer  of  the  stomach,  as  was 
indicated  by  the  dyspeptic  manifestations.  The  examination  of  the  stom- 
ach-contents revealed  an  abundance  of  free  hydrochloric  acid,  acidity  50  ;t 
the  filtrate  had  a  digestive  action.  An  involvement  of  the  stomach  was 
thus  excluded.  The  correctness  of  this  diagnosis  was  verified  by  the 
autopsy. 

In  large  tumors  percussion  may  reveal  a  circumscribed  area  of 
dullness,  yet  it  is  hardly  necessary  for  me  to  state  that  the  percus- 

*  Virehow.     Wiener  med.  Wochenschr.,  1857,  No.  26. 
t  Ewald.     Berl.  klin.  Wochenschr.,  1886,  No.  33. 
i  [See  p.  32.— Te.] 


DIAGNOSIS  OF  CANCER.  201 

sion  note  will  vary  considerably  according  to  the  amount  of  air  in 
the  stomach  and  intestines,  and  according  to  the  force  used.  The 
best  results  are  obtained  by  very  delicate  direct  percussion  with  the 
linger,  or  by  auscultatory  percussion.  Small  tumors  may  at  times 
be  inaccessible  to  both  percussion  and  palpation  by  a  twisting  of  the 
stomach  on  its  axis,  yet  they  may  be  rendered  demonstrable  by  in- 
flation of  the  stomach  or  intestines. 

At  times  the  tumor  may  pulsate  distinctly  when  it  lies  upon  the 
aorta  and  is  lifted  by  it.  This  pulsation,  which  may  be  very  marked, 
and  owing  to  the  retraction  of  the  abdominal  parietes  may  seem  to 
be  just  beneath  them,  is  distinguished  from  pulsation  of  the  aorta 
by  the  fact  that  a  tumor  only  expands  in  a  vertical  direction,  while 
the  aorta  does  so  both  vertically  and  laterally.  However,  this  does 
not  always  suffice  ;  if  the  tumor  surrounds  the  aorta,  as  occurred  in 
Ott's  case,*  all  the  symptoms  of  an  cortic  aneurism  may  be  j)resent : 
transverse  and  vertical  pulsation,  systolic  bruit  and  distinct  thrill 
over  the  tumor,  smallness  of  the  femoral  arteries,  even  a  swelling  in 
the  back  may  be  present ;  we  may  sometimes  also  observe  symptoms 
which  are  exactly  similar  to  those  occurring  when  a  calcareous  an- 
nular infiltration  has  developed  in  the  walls  of  the  aorta  and  has 
caused  a  stenosis  of  the  vessel  and  a  dilatation  above  the  site  of  the 
stricture.  At  all  events,  a  diiferential  diagnosis  in  such  cases  is  out 
of  the  question. 

Hard  fecal  masses  in  the  transverse  colon  or  jejunum  may  simu- 
late a  tumor  ;  hence  the  rule  :  Always  previously  evacuate  the  bow- 
els thoroughly  in  every  doubtful  case.  This  is  so  self-evident  that  I 
ought  scarcely  to  mention  it.  Yet  in  practice  I  find  that  this  point 
is  very  frequently  disregarded,  in  spite  of  the  fact  that  it  is  men- 
tioned in  every  text-book. 

In  many  cases  there  is  continuous  pain  at  the  site  of  the  neo- 
plasm ;  its  manifold  character  has  already  been  discussed  under  the 
general  symptoms.  In  other  cases  the  pain  varies,  at  times  ceasing 
entirely  or  being  simply  manifested  as  a  vague  burning  sensation  or 
oppression  in  the  epigastrium.  The  exacerbations  of  pain  are 
usually  due  to  fresh  inflammatory  processes  or  the  develo|)ment  of 

*  Ott.    Loc.  cit,  p.  73. 


202  DISEASES  OF  THE  STOMACH. 

new  tumors,  or  finally  to  traction  on  the  walls  of  the  stomach,  owing 
to  the  firm  adhesions  with  the  adjacent  movable  viscera.  Propaga- 
tion of  the  pain  downward  into  the  umbilical  and  suprapubic  re- 
gions renders  it  very  probable  that  the  neoplasm  is  advancing  along 
the  peritonseum ;  occasionally  distinct  friction  sounds  may  be  heard, 
especially  in  the  hepatic  region  ;  sometimes  a  rubbing  may  also  be 
felt. 

4.  The  cancerous  cachexia.  The  peculiar  condition  of  patients 
with  cancer,  which  is  called  the  cancerous  cachexia,  appears  almost 
without  exception  sooner  or  later  in  the  course  of  the  disease,  and 
has  afforded  various  authors  an  opportunity  to  write  more  or 
less  poetical  descriptions.  Unfortunately,  this  condition  may  give 
rise  to  errors  both  positive  and  negative.  The  latter  are  due  to  the 
fact  that  it  is  usually  absent  at  the  beginning  or  during  the  first  half 
of  the  disease,  just  at  the  time  when  it  would  be  of  the  greatest  serv- 
ice to  render  a  diagnosis  certain.  I  have  already  had  an  oj)por- 
tunity  to  present  to  you  a  patient  who  undoubtedly  had  been  suffer- 
ing for  months  from  a  cancer  at  the  pylorus,  and  yet  his  severe 
malady  would  have  been  suspected  by  no  one. 

A  few  weeks  ago  I  was  called  to  see  a  patient  in  whom  I  could  very 
easily  palpate  an  immense  nodular  tumor,  occupying  the  entire  epigas- 
trium, and  also  adherent  to  the  liver.  The  patient  claims  to  have  been 
well  up  to  two  weeks  ago  and  to  have  followed  his  usual  occupation  till 
then;  also  that  neither  his  family  nor  his  friends  noticed  anything  pe- 
culiar about  him.  The  first  symptom.s  noticed  were  jaundice  and  oedema 
of  the  lower  extremities,  which  appeared  suddenly.  Even  when  I  saw 
him  there  was  no  trace  of  a  true  cachexia,  and  yet  the  neoplasm  was 
evidently  of  long  standing. 

On  the  other  hand,  you  will  not  infrequently  see  persons  with  a 
typical  cancerous  cachexia,  and  whose  history,  as  well  as  the  results 
of  the  examination,  point  strongly  toward  cancer,  yet  after  a  longer 
or  shorter  course  of  treatment  they  recover  entirely,  and  thus  afford 
a  most  striking  proof  to  the  contrary.  Disregarding  manifest  dis- 
eases whose  nature  may  be  discovered,  it  is  almost  superfluous  to 
say  that  in  this  class  of  patients  the  most  important  place  is  occu- 
pied by  hysteria  in  all  its  varieties.  Every  physician  knows  to  what 
extent  the  emaciation  and  loss  of  strength  of  hysterical  patients  may 
sometimes  reach.     Even  if  we  disregard  the  other  characteristic 


DIAGNOSIS  OF  CANCER.  203 

symptoms  as  a  whole,  it  will  be  observed  that  in  hysterical  cachexia 
the  turgescence  of  the  skin  is  well  preserved,  in  marked  contrast  with 
the  condition  of  the  skin  in  cancer  ;  this  is  a  valuable  diagnostic 
sign.  The  differentiation  is  rendered  still  more  difiicult  in  the  hys- 
teria of  male  subjects. 

Some  time  ago  I  was  associated  with  a  local  colleague  in  the  treatment 
of  a  m.an,  forty  years  old,  who  had  lost  thirty  pounds  in  two  months ;  he 
had  quite  a  marked  but  not  extreme  cachexia,  and  a  variety  of  symptoms, 
among  which  were  complete  anorexia,  marked  fetor  of  the  breath,  and 
oppression  over  the  epigastrium  ;  these  led  to  the  suspicion  of  a  rapidly 
growing  organic  lesion.  In  addition,  the  j)atient  also  suffered  from  pal- 
pitation of  the  heart  and  attacks  of  dyspnoea,  apparently  of  a  severe  form ; 
he  also  had  strange  sensations,  especially  a  very  peculiar  and  annoying 
feeling  as  if  his  limbs  were  "  dead  and  ice-cold."  Other  physicians  had 
expressed  an  uiifavorable  prognosis,  and  this  had  not  failed  to  exert  a 
very  depressing  effect  on  his  already  irritable  disposition.  He  lay  in  bed 
for  weeks  and  protested  that  he  was  unable  to  leave  it.  The  latter  symp- 
tom, the  cardiac  palpitation,  the  dyspnoea,  the  peculiar  sensations  for 
which  we  could  find  no  cause  either  in  the  circulatory  or  respiratory  sys- 
tem (there  was  a  moderate  dullness  on  the  right  side  posteriorly,  but  this 
proved  to  have  been  due  to  a  temporary  atelectasis) — all  these  led  us  to 
assume  the  presence  of  hysteria  complicated  with  a  very  severe  gastric 
catarrh,  possibly  due  indirectly  to  the  latter.  We  began  suitable  treat- 
ment, and  its  success  proved  the  correctness  of  our  supj)osition ;  all  of  the 
symptoms  disappeared,  and  the  patient  was  discharged  cured,  after  four 
weeks'  treatment,  including  washing  OLit  the  stomach  with  a  watery  solu- 
tion of  thymol  ;  the  other  drugs  used  were  hydrochloric  acid,  bromide  of 
potassium,  and  valerian. 

In  this  case  the  patient's  age  was  an  important  factor,  pointing 

against  the  presence  of  a  neoplasm.     But  here  also  very  remarkable 

sources  of  error  may  be  encountered. 

On  June  19,  1886,  a  physician  consulted  me  about  bis  mother,  a  lady  a 
little  over  fifty  years  old,  who  was  so  extremely  emaciated  and  feeble,  the 
^skin  so  sallow  and  dry,  that  at  first  glance  she  looked  as  if  she  had  can- 
cerous cachexia.  She  had  severe  stomach  symptoms,  especially  pain  after 
eating  ;  she  was  not  relieved  till  she  had  belched  repeatedly.  In  conse- 
quence of  this  she  kept  a  very  strict  and  innutritious  diet,  and  had  ema- 
ciated as  described  above.  On  closer  observation,  or  rather  waiting,  it 
became  evident  that  the  whole  trouble  was  hysteria.  She  suffered  from 
such  an  attack  of  belching  during  the  first  examination ;  for  almost  half 
a  minute  the  gas  was  raised  with  a  rapid  succession  of  hiccoughs  and  wdth 
a  rumbling  noise  almost  like  thunder,  and  yet  the  abdomen  was  not  much 
distended.  This  was  frequently  repeated  at  short  intervals,  the  whole  at- 
tack giving  one  the  impression  of  a  brief  cyclone.  The  results  of  the  phys- 
ical and  chemical  examination  of  the  stomach  were  normal,  and  the  same 
was  true  of  the  stool  as  was  ascertained  later.    , 


204:  DISEASES   OF   THE  STOMACH. 

,  The  diagnosis  of  hysteria  had  naturally  been  already  made  by  other 
physicians,  and  the  entire  array  of  nervines  had  been  tried.  I  thought  of 
a  case  which  I  had  seen  long  ago  at  the  clinic  of  Prof,  von  Frerichs,  in 
which  an  hysterical  spasm  of  the  glottis  promptly  ceased  whenever  the 
electrodes  were  placed  upon  the  cervical  vagi  and  an  induced  current 
passed  through  them.  This  expedient  was  similarly  successful  in  this 
case,  as  the  attack  ceased  instantly  on  applying  the  current.  But,  as  I 
wished  to  effect  a  permanent  as  well  as  a  temporary  cure,  I  concluded  to 
wash  out  the  patient's  stomach  at  regular  intervals,  on  the  presumption 
that  the  mechanical  irritation  and  the  harsh  treatment  of  the  gastric  mu- 
cous membrane  would  thus  lessen  the  hyperaesthesia  of  the  organ.  I 
shall  leave  undecided  whether  this  presumption  was  correct  or  whether 
the  good  result  was  due  to  the  erratic  whim  of  an  hysterical  patient,  which 
has  so  frequently  contributed  to  the  success  of  what  seemed  to  be  the  most 
wonderful  remedies.  At  all  events,  these  troublesome  symptoms  disap- 
peared after  five  seances,  and  according  to  a  recent  report  have  never 
returned. 

Let  this  suffice  to  emphasize  once  more  the  fact,  which  is  already 
well  known,  that  tlie  cancerous  cachexia  regarded  alone,  and  as  the 
only  symptom,  is  of  doubtful  trustwortliiness. 

Finally,  I  must  discuss  the  differential  diagnosis  in  so  far  as  it 
has  not  already  been  considered.  The  lesions  in  question  are 
especially  gastric  ulcer,  severe  catarrhal  gastritis,  atro|)liy  and  amy- 
loid degeneration  of  the  mucous  membrane  of  the  stomach,  and 
marked  cases  of  hysteria  and  neurasthenia.  I  must  premise  that 
at  times  a  sharp  differentiation  of  these  conditions  may  be  impos- 
sible during  life ;  in  other  cases  there  may  be  phases  in  the  course 
of  the  disease  in  which  every  factor  for  a  positive  diagnosis  may 
be  lacking.  At  all  events,  the  presence  or  absence  of  free  hydro- 
chloric acid  affords  a  degree  of  certainty  unattained  until  a  few 
years  ago.  That  it  is  not  always  absolute  I  have  already  endeavored 
to  impress  on  you ;  for  it  may  be  absent  not  alone  in  carcinoma, 
but  it  may  also  be  permanently  wanting  in  severe  gastric  catarrhs, 
and  in  atrophy  of  the  gastric  mucosa,  and  may  also  not  be  found 
for  a  long  time  in  hysteria,  and  even  in  neurasthenia.  Then  there 
are  also  the  unquestionable  although  rare  cases  of  cancer  without 
loss  of  hydrochloric  acid.  The  same  is  true  of  ulcer  of  the  stomach, 
where,  although  as  a  rule  there  is  hyperacidity,  yet  cases  occur 
in  which  the  secretion  of  hydrochloric  acid  is  scanty.  From  these 
statements  you  will  once  more  be  able  to  appreciate  the  value  of 
the  estimation  of  hydrochloric  acid.     I  think  that  you  will  agree 


DIFFERENTIAL  DIAGNOSIS  OP  CANCER.  205 

with  me  that  even  though  it  is  not  a  touchstone,  as  some  enthusiasts 
would  claim,  yet  it  is  a  diagnostic  aid  of  the  greatest  value. 

The  demonstration  of  the  presence  of  a  tumor  will  remain  as 
ever  the  most  important  and  decisive  feature.  Here  we  must  be 
careful  not  to  mistake  tumors  situated  outside  of  the  stomach,  or 
hypertrophic  tumor-like  thickening  at  the  pylorus,  gastroliths,  and 
similar  lesions  already  discussed  on  page  312  et  seq.  Where  a 
tumor  has  not  been  demonstrated  the  diagnosis  may  be  only  rela- 
tively certain  ;  thus  it  is  not  at  all  positive  in  atrophy  of  the  gastric 
mucosa,  which  may  completely  simulate  a  slowly  and  steadily  grow- 
ing carcinoma  because  both  hydrochloric  acid  and  rennet  are  per- 
manently absent.  The  absence  of  the  cancerous  cachexia  may  be  of 
importance,  since  it  aj^pears  to  be  less  developed  in  atrophy.  But 
not  a  few  cases  have  been  reported  in  which  extensive  carcinoma- 
tous processes  ran  their  course  without  any  special  symptoms. 
Thus  Storer*  rej)orts  a  case  in  which  almost  the  entire  stomach 
underwent  colloid  degeneration  without  causing  any  marked  dis- 
turbances of  digestion  and  vomiting.  Sieweckef  has  collected 
twelve  similar  cases  in  which  the  characteristic  symptoms  of  cancer 
were  absent  throughout. 

I  recently  had  an  opportunity  to  perform  an  autopsy  on  a  man, 
twenty-nine  years  old,  who,  up  to  four  weeks  before  his  death,  had  been 
able  to  undergo  a  Playfair  [Weir  Mitchell]  treatment  for  a  supposed 
neurasthenia  without  disturbing  his  digestion  in  any  way  !  Before  that 
time  an  abdominal  tumor  could  not  be  palpated  ;  later  a  haemorrhagic 
pleurisy  was  developed,  and  the  patient  died  in  coma.  I  found  a  general 
widely  distributed  "  carcinomatous  "  condition.  The  stomach  was  imbedded 
in  nodular  masses,  its  walls  doubled  in  thickness,  its  diameter  about  that 
of  a  transverse  colon  of  medium  size.  The  microscope  showed  that  the 
mucosa  was  almost  entirely  infiltrated  with  a  flbro-sarcomatous  neoplasm ; 
only  in  small  areas  were  the  short  and  long  glandular  tubules  intact,  but 
the  epithelium  was  very  granular  and  cloudy,  and  the  contours  of  the 
cells  were  destroyed.  Stomach  digestion  had  undoubtedly  been  impos- 
sible long  before,  and  the  food  probably  passed  through  the  stomach  as  if 
it  were  a  prolongation  of  the  oesophagus ;  the  intestii>es  had  been  able 
to  carry  on  this  severe  labor  of  digestion  up  to  a  short  time  before  death. 
Thus  the  case  may  be  added  to  those  already  cited  where  the  nutritive 
processes  were  kept  up,  although  the  digestive  functions  of  the  stomach 

*  Storer.  Colloid  Disease  of  the  Entire  Stomach,  with  Tery  Few  Symptoms. 
Boston  Med.  and  Surgical  Journal,  October  10,  1873. 

f  Siewecke.     Ueber  Magenkrebs.     Inaug.  Diss.     Berlin,  1868. 


206  DISEASES  OF  THE  STOMACH. 

had  been  entirely  lost,  and  tlie  whole  task  had  been  assumed  by  the 
intestines. 

In  this  category  must  also  be  placed  the  cases  in  which  the 
disease  is  occult  for  a  long  time,  or  is  only  manifested  by  vague 
dyspeptic  symptoms  ;  but  subsequent  to  or  apparently  because  of  a 
marked  change  in  the  metabolism,  great  worry,  or  a  very  different 
mode  of  life — i.  e.,  a  "  Schweninger  cure,"  or  an  exhausting  course 
of  treatment  at  a  mineral  spring — suddenly  the  entire  group  of 
symptoms  of  cancer  of  the  stomach  is  rapidly  developed.  The 
patients  imagine  that  they  have  discovered  the  cause  of  their 
ailment ;  while  the  truth  is,  that  the  change  of  the  metabolism 
has  simply  weakened  the  organism's  power  of  resistance  against 
the  neoplasm,  or,  in  other  words,  has  favored  the  growth  of  the 
carcinoma. 

The  differential  diagnosis  between  ulcer  and  cancer  of  the  stom- 
ach will  be  discussed  at  length  in  the  next  lecture.  Here  I  shall 
simply  state  that  hydrochloric  acid  and  the  ferments  (pejjsin  and 
rennet)  are  always  present  in  the  former,  but  are  absent  in  the 
great  majority  of  cases,  of  the  latter.  Experience  has  shown  that 
an  ulcer  does  not  protect  a  patient  against  cancer,  but  it  seems  that 
if  the  latter  already  exists  the  former  is  never  added.  The  follow- 
ing may  serve  to  establish  the  diagnosis : 

1,  The  appetite  in  ca.ncer  is,  as  a  rule,  more  profoundly  and 
permanently  impaired.  In  ulcer  it  is  lost  only  during  the  exacer- 
bations, but  is  normal  in  the  remissions  and  intermissions,  although 
the  fear  of  causing  pain  makes  the  patients  eat  little  or  hardly  at 
all.  As  already  stated,  the  condition  of  the  tongue  is  very  charac- 
teristic :  in  ulcer  it  is  usually  clean,  or  only  coated  at  the  base ;  in 
cancer  it  is  furred  in  the  great  majority  of  cases. 

2.  The  pain  is  generally  more  localized  in  ulcer,  and  is  usually 
limited  to  the  epigastric  region  and  the  left  parasternal  line. 
Corresponding  to  the  frequency  of  the  situation  of  ulcer  on  the 
posterior  wall  of  the  stomach  (43  per  cent),  the  pain  very  fre- 
quently radiates  backward,  the  so-called  lumbar  pain  {Kreuz- 
schmerz) ;  the  pain  is  usually  aggravated  or  caused  by  external  influ- 
ences— taking  food,  pressure  from  without,  certain  bodily  move- 
ments and  postures,   and   sometimes   even    by  the   simple   act   of 


DIFFERENTIAL  DIAGNOSIS  OF   CANCER.  207 

breathing.  In  cancer  it  is  usually  continiions,  less  intense,  and  not 
occurring  in  paroxysms.  Yet  the  most  manifold  variations  may 
occur  in  both. 

3.  In  ulcer  vomiting  stands  in  an  undeniable  relation  to  the 
pain,  and,  like  it,  is  irregular  and  changeable ;  as  a  rule,  it  occurs 
^t  an  early  stage  of  the  disease,  while  in  cancer  it  is  usually  absent 
during  the  first  few  months,  but  later  becomes  gradually  more 
frequent.  Ott  very  properly  says  that  in  cancer  vomiting  dejDends 
upon  the  site  of  the  tumor ;  in  ulcer,  upon  the  intensity  and  dura- 
tion of  the  pain.  The  presence  of  characteristic  kinds  of  tissue  in 
the  vomit,  its  admixture  with  blood,  and  the  vomiting  of  pure 
blood,  have  all  been  discussed  under  the  symjDtoms.  I  shall  merely 
add  that  haemorrhage  is  relatively  and  absolutely  more  frecpient 
in  ulcer ;  its  severity  is  also  more  marked  in  this  lesion.  On  the 
other  hand,  the  intervals  between  the  haemorrhages,  or  a  relatively 
brief  series  of  them,  are  much  longer  in  ulcer,  Avhile  in  cancer, 
having  once  begun,  they  recur  more  frequently  or  permanently. 
If  you  are  called  to  a  patient  with  severe  htemorrhage  from  the 
mouth  and  anus,  which  has  occurred  suddenly,  and  has  been  so 
severe  that  there  is  danger  of  collapse  from  the  profound  anaemia, 
from  these  points  alone  you  may  make  a  diagnosis  of  ulcer  with 
reasonable  certainty. 

The  mistaking  of  the  so-called  essential  or  idiopathic  angemia  for 
carcinoma,  or,  on  the  other  hand,  the  failure  to  recognize  a  cancer, 
probably  occurs  less  frequently  with  us  in  Germany  than  it  does 
elsewhere.  At  least,  in  English  literature  I  have  found  the  reports 
of  quite  a  number  of  such  cases  in  which  a  careful  examination  of 
the  blood  and  of  the  stomach-contents  ought  to  have  prevented  such 
errors. 

Finally,  cancer  must  be  distinguished  from  the  severe  forms  of 
hysteria.  At  tlie  first  glance  it  would  seem  almost  impossible  to 
mistake  these  two  conditions,  and  yet  there  undoubtedly  occur  cases 
in  which  an  extemporaneous  diagnosis  is  not  to  be  made,  and  even 
prolonged  observation  may  leave  us  in  doubt.  I  do  not  like  to  ac- 
knowledge the  possibility,  yet  it  has  happened  more  than  once  that 
hysterical  women  have  for  years  swallowed  portions  of  their  hair ; 
these  hairs  form  coils  in  the  stomach,  and  may  readily  simulate  a 


208  DISEASES   OF  THE  STOMACH. 

tumor.*  But,  even  without  these  "  comphcations,"  severe  forms  of 
liysteria  may  lead  to  such  a  marked  disturbance  of  nutrition  that, 
especially  when  occurring  in  elderly  women,  the  suspicion  of  a  can- 
cer will  always  arise.  But,  as  a  rule,  you  will  discover  one  or  an- 
other characteristic  symptom  which  will  enable  you  to  make  a  posi- 
tive diagnosis. 

Treatment. — The  old  proverb  that  no  drug  is  potent  against  can- 
cer is  true  even  to-day,  however  dejoressing  such  an  admission  may 
be.  From  time  to  time  a  host  of  specifics  has  appeared,  from  cicuta 
and  belladonna  of  the  elder  Yogel,  Storck,  and  Hufeland,  down  to 
the  condurango  bark  of  Friedreich,  of  Heidelberg ;  they  all  owe 
their  ephemeral  popularity  to  a  conscious  or  unconscious  decep- 
tion. At  best,  like  condurango,  they  only  relieve  symptoms ;  they 
lessen  the  accompanying  catarrh  and  increase  the  digestive  activity 
of  the  organ,  but  a  true  curative  action,  in  the  strict  sense  of  the 
word,  does  not  belong  to  them.  The  recommendation  of  condu- 
rango in  1874  by  Friedreich  was  based  upon  a  solitary  case,  and,  at 
that,  one  in  which  no  autopsy  was  made  !  In  this  case  it  was  said 
that  after  the  prolonged  use  of  the  remedy  a  carcinoma  was  reduced 
to  the  size  of  a  small  tumor,  and  that  the  accompanying  swelling  of 
the  lymphatic  glands  had  disappeared.  Like  so  many  of  our  new 
remedies,  it  owes  its  reputation  as  a  specific  to  the  implicit  faith  of 
some  half-civilized  or  wild  Indians,  and  to  the  speculation  of  enter- 
prising exporters.  At  first  it  was  received  with  acclamation  by  the 
medical  world,  which  is  pervaded  by  a  surprising  ndwete  and  an 
ineradicable  optimism  whenever  new  specifics  for  incurable  diseases 
are  introduced.  It  was  indiscriminately  tried  in  every  variety  of 
cancer ;  the  first  flush  of  enthusiasm  was  soon  followed  by  a  disap- 
pointment which  threatened  to  thrust  the  remedy  back  into  oblivion. 
The  one  extreme  is  as  bad  as  the  other.  For  a  long  time  it  was 
praised  and  condemned  without  a  thorough  and  rnethodical  series 
of  experiments  having  been  conducted.  Such  an  examination  was 
first  made  on  a  few  cases  by  Immermann ;  then  Riess  investigated 
it  in  a  large  number  of  cases  from  a  similar  standpoint :  these  re- 


*  Bussel.     A  Case  in  which  the  Cavity  of  the  Stomach  was  occupied  by  an  Enor- 
mous Mass  of  Human  Hair.     Medical  Times  and  Grazette,  June  2G,  1869. 


TREATMENT  OF   CANCER. 


209 


suits  liave  recently  been  published.*  Immermann's  cases  were  not 
all  pure  examples  of  cancer  of  the  stomach  ;  upon  his  series  he  esti- 
mates the  ratio  of  fatal  cases  treated  with  condurango  to  be  1  as  against 
1*3  without  this  remedy.  Riess  endeavored  to  limit  the  drug  espe- 
cially to  patients  with  cancer  of  the  stomach,  and,  after  having  ob- 
served 80  cases  with  this  treatment  and  116  without  it,  he  claims 
that  condurango  has  a  specific  action.  It  is  readily  taken  by  patients 
for  a  long  time,  and  it  is  said  that  under  its  prolonged  use  palpable 
tumors  disappeared,  and  the  general  condition  progressively  improved 
botli  subjectively  and  objectively.  "  In  a  large  number  of  cases  the 
impartial  observer  became  positively  impressed  with  the  fact  that 
life  was  considerably  prolonged  under  treatment  with  condurango." 
The  following  table  shows  the  result  upon  the  mortality  and  the 
duration  of  the  treatment : 


Average 
duration  of 

treatment 
of  all  cases. 

Deaths. 

Average 
duration  of 
treatment. 

Discharged. 

Average 
duration  of 
treatment. 

Cases     with     condu- 
ransTO  (80). 

43-4  days 
21-2  days 

53  (=  66-3^) 
107  (=  92-2^) 

39-5  days 
22-0  days 

27  (=  33-7^) 

9  (=  rm 

54-8  days 
11*7  days 

Cases  without  condu- 
rango (IIG) 

It  is  to  be  noted  that  the  proportion  of  fatal  cases  with  and  with- 
out this  treatment  is  1  :  1*4  (according  to  Immermann,  1  : 1'3) ;  thus, 
the  results  of  Kiess  and  Immermann  are  almost  the  same.  This 
would  have  been  very  convincing  had  the  diagnosis  of  gastric  cancer 
been  positively  made  in  all  the  cases,  and  had  the  discharged  patients 
been  watched  for  a  long  period ;  but  this  substantial  basis  is  want- 
ing in  these  observations,  and  Riess  himself  betrays  his  own  doubt, 
inasmuch  as  he  is  always  very  careful  to  speak  only  "  of  the  group 
of  symptoms  of  gastric  cancer "  {von  dem  Symjptomencojnplex  des 
Magenhrebses).  It  is  also  to  be  regretted  that  this  writer  did  not 
give  more  definite  information  as  to  the  situation  of  the  tumor,  and 
that  he  did  not  verify  his  diagnoses  by  the  aid  of  the  newer  meth- 
ods. He  also  neglects  to  state  whether  the  clinical  diagnosis  was 
always  verified  by  autopsies.     This  is  the  more  to  be  regretted,  since 


*  L.  Riess.     Ueber  den  Werth  der  Condurangorinde  bei  dera  Symptombilde  des 
Magencarcinoms.     Berl.  klin.  Wochenschr.,  1887,  No.  10. 
14 


210  DISEASES  OF  THE  STOMACH. 

in  three  cases  of  supposed  cured  or  improved  cancer  wliicli  subse- 
quently died  of  other  causes,  and  which  were  examined  ]po8t  mortem^ 
the  diagnosis  made  during  life  was  not  free  from  doubt ;  for,  from 
the  brief  notes  of  these  three  autopsies  given  by  Riess,  it  would  seem 
much  more  probable,  if  not  indeed  actually  so,  that  the  lesion  was  an 
old  cicatrized  ulcer. 

Hence  the  publications  thus  far  on  the  specific  action  of  condu- 
rango  are  by  no  means  convincing  to  me.  You  may  object,  and  say 
that  the  involution  of  palpable  tumors  which,  as  Riess  claims,  may 
even  be  observed  with  a  tape-measure,  is  a  very  significant  occur- 
rence. In  answer  to  this,  I  claim  that  the  improvement  of  the  con- 
comitant catarrh  of  the  mucous  membrane  may  lessen  the  hyper- 
gemia  and  the  size  of  the  tumor.  It  is  also  a  well-known  fact,  to 
which  I  have  directed  attention,  that  abdominal  tumors  always  seem 
larger  than  they  really  are  when  palpated  through  the  abdominal 
walls,  and  hence  increase  or  diminution  in  size  will  be  manifested 
on  a  larger  scale.  How  often  do  we  believe  we  have  palpated  a 
pyloric  tumor  about,  the  size  of  a  walnut  or  a  hen's  ^^^  which,  on 
autopsy  proves  to  have  been  only  an  insignificant  muscular  hyper- 
trophy of  the  cervix  pylori !  * 

These  remarks  are  not  intended  to  question  the  beneficial  infiu- 
ence  of  condurango  on  the  general  condition  in  gastric  cancer,  as  I 
have  frequently  had  the  opportunity  of  convincing  myself  of  this 
action.  It  is  eminently  proper  that  the  remedy  should  be  exten- 
sively used,  since  Riess's  observations  on  this  point  are  very  impor- 
tant ;  yet,  in  spite  of  Orszewsky  and  Erichsen,f  one  should  not 
■expect  to  cure  cancer  of  the  stomach  wi^h  it.  The  accompanying 
gastric  catarrh  is  improved,  and  the  same  beneficial  effects  are 
•obtained  in  genuine  catarrhal  diseases  of  the  gastric  mucous  mem- 
brane ;  hence  condurango  may  be  considered  an  excellent  stomachic 


*  According  to  Retzius,  I  would  thus  designate  that  portion  of  the  pyloric  ring 
■which  in  such  ciises  projects  into  the  duodenum,  as  the  cervix  uteri  does  into  the 
<vagina,  Bemerkungen  iiber  das  Antrum  pylori  beim  Menschen.  Miiller's  Archiv, 
1857. 

f  Zur  Casuistik  der  Condurangowirkung  bei  Carcinom.  Petersburg,  med. 
Wochenschrift,  1876,  Nos.  2,  3.  These  writers  claim  to  have  observed  a  stimula- 
tion in  the  production  of  connective  tissue,  with  a  coincident  destruction  of  the 
cellular  elements  of  the  cancer. 


TREATMENT  OF  CANCER.  211 

in  all  those  cases  in  wliicli  a  true  catarrhal  condition  of  the  gastric 
mucosa  exists — i.  e.,  the  secretion  of  a  sero-mucous  fluid,  with  a 
more  or  less  abundant  admixture  of  pus.  Condurango  is  best 
administered  in  a  maceration  decoction,  25*0  to  200*0  [i.  e.,  5  ^'j  of 
a  1 :  8  decoction] — to  last  two  days ;  and  as  the  amount  of  hydro- 
chloric acid  in  these  cases  is  always  lessened,  it  is  well  to  add  0*3  to  0'5 
per  cent  of  this  acid,  and  a  carminative  syrup  like  syr.  zingiberis, 
or  syr,  foeniculi  (Ph.  Germ.),  or  syr.  menthse  (Ph.  Germ.).  *  Immer- 
mann  has  given  directions  for  making  a  condurango  wine.  The 
alcoholic  extraction  increases  the  cost  of  the  remedy  without,  so 
far  as  we  know,  extracting  any  special  ingredients  from  the  bark. 
For  this  reason,  when  it  is  indicated,  I  usually  order  the  watery 
extract,  and  a  good  wine  to  be  taken  separately.  [In  the  United 
States  the  preparation  usually  employed  is  the  fluid  extract,  in 
doses  of  a  drachm  or  more.]  f 

Thus,  after  all,  the  treatment  must  be  restricted  to  the  symp- 
toms. 

Vomiting  ceases  or  is  lessened  by  swallowing  small  pieces  of 
ice  with  a  few  drops  of  chloroform,  ice-cold  carbonic  water  in  tea- 
spoonful  doses,  effervescing  lemonade  or  champagne  (one  of  my 
patients  insisted  on  having  "  weiss  Bier "  for  his  vomiting,  and 
bore  it  well),  and  morphine  internally  or  hypodermically.  Occa- 
sionally, temporary  relief  may  be  obtained  by  the  use  of  supposi- 
tories with  10  to  25  milligrammes  [gr.  \  to  ■^]  of  opium. 

The  action  of  ferric  chloride,  which  was  formerly  so  highly 
lauded  in  hmmaiemesis,  is  very  doubtful ;  it  is  also  hard  to  under- 
stand how  it  can  act  when  given  in  the  dilution  necessary  to  prevent 
corrosion.  ISTature  has  provided  for  the  stoppage  of  heemorrhage 
from  the  smaller  vessels  by  means  of  thrombosis ;  the  bleeding 
from  larger  vessels  can  not  be  influenced  by  ferric  chloride.     Much 


*  [Syrup  of  fennel  and  of  peppermint  (Pharm.  German.)  are  both  lO-per-cent 
solutions. — Tr.] 

t  [Suflficient  time  has  not  yet  elapsed  to  pass  a  correct  judgment  on  the  new 
specific  against  inoperable  malignant  neoplasms,  methylene  blue,  which  was  pro- 
posed by  Prof,  von  Mosetig-Moorhof  (Wiener  klin.  Wochenschr.,  1891.  No.  6,  p.  101 : 
ib.,  No.  12,  p.  24.)  The  general  tendency,  however,  is  unfavorable  toward  the 
claims  of  its  specific  action.  For  bibjiography.  see  W.  Meyer.  Notes  on  the  Effects 
of  Aniline  Dyes,  etc.     New  York  Med.  Record,  vol.  xxxix,  pp.  473-478. — Tr.] 


212  DISEASES  OP  THE  STOMACH. 

better  results  are  obtained  bj  cold  (eating  cracked  ice,  and  cold 
compresses  to  tlie  abdomen)  and  ergot.  I  order  a  doubly  purified 
extract  of  secale  cornutum  (Pharm.  Germ.)  in  a  50-per-cent  solu- 
tion of  glycerin  and  water ;  of  tliis  I  inject  two  to  three  Pravaz 
syringefuls  ^  in  the  epigastrium  in  the  course  of  half  an  hour ;  we 
may  also  give  10  to  20  drops  of  this  solution  internally  every  hour.f 
We  may  use  ergot  freely,  since  it  has  been  calculated  that  the 
poisonous  effects  of  sclerotinic  acid  do  not  appear  in  human  beings 
till  about  10  grammes  [  3  ijss-]  have  been  taken.  Our  knowledge 
of  sclerotinic  acid  being  still  vague,  it  is  better  to  use  the  extract  of 
ergot.  However,  the  effectiveness  of  the  remedy  must  not  be 
judged  by  the  possible  results  in  controlling  the  bleeding  in  cases  of 
cancer,  where  the  walls  of  the  blood-vessels  are  degenerated  and 
adherent  to  a  more  or  less  rigid  tumor.  Its  action  is  much  more 
pronounced  in  gastric  ulcer  {q.  v.). 

As  mild  analgesics  we  may  try  rubbing  in  chloroform  liniment, 
hydropathic  applications  with  chamomile  infusion,  warm  poultices, 
affusions  to  the  abdomen,  etc.  I  have  obtained  no  good  results  from 
cocaine  in  this  disease ;  chloral  has  been  more  useful,  yet  at  times 
the  hypnotic  effect  predominated  too  much  over  its  sedative  action. 
The  preparations  of  opium  labor  under  the  great  disadvantage  that 
they  paralyze  still  further  the  already  retarded  intestinal  peristalsis. 
This  is  especially  true  of  opium,  since  it  is  well  known  that  mor- 
phine or  codeine  affects  the  intestines  much  less.  Yet,  even  here, 
we  encounter  idiosyncrasies,  so  that  the  use,  for  a  few  days,  of  very 
small  doses  of  morphine,  only  5  to  10  milligrammes  [gr.  Jg-  to  ^], 
may  cause  obstinate  constipation.  Belladonna  has  for  a  long  time 
enjoyed  the  reputation  of  being  antagonistic  to  this  action  of  opium, 
but,  as  a  rule,  it  has  been  given  in  too  small  doses.  "We  may  add 
20  to  50  milligrammes  [gr.  ^  to  |]  of  extract  of  belladonna  to  10 


*  [The  capacity  of  the  Pravaz  hypodermic  syringe  is  one  gramme  (15  minims). 
— Tr.1 

f  [For  hypodermic  use  good  fluid  extracts  of  ergot,  like  Squibb's,  Wyeth's,  etc., 
diluted  with  one  or  two  parts  of  water,  answer  every  purpose.  Sometimes  the 
solution  is  not  clear ;  if  this  is  the  ease,  it  is  unfit  for  use.  The  injections  should 
be  carefully  made  ;  yet,  sometimes,  in  spite  of  all  care,  painful  spots,  or  even  small 
abscesses,  are  left.  Cold  applications  of  witch-hazel  are  very  soothing  if  pain  is 
present  at  the  site  of  the  injection. — Tr.] 


TREATMENT  OP  CANCER.  213 

milligrammes  [gr.  -|-]  of  morphine ;  for  hypodermic  use  add  -Jg-  part 
of  sulphate  of  atropine.  But  all  persons  do  not  react  alike  to  bella- 
donna ;  hence,  dilatation  of  the  pupils,  dryness  of  the  tongue,  and 
irritation  in  the  throat  may  occur  very  early,  and  after  very  small 
doses.  It  is  therefore  advisable  to  warn  patients  of  the  possible 
effects  of  the  drug.  A  patient  with  cancer  of  the  large  intestines 
and  metastases  in  the  liver  and  retroperitoneal  glands  once  refused 
to  take  some  pills  because  he  read  extract  of  belladonna  on  the 
prescription.  He  asserted  that  he  was  at  once  affected  with  a  most 
annoying  dryness  in  the  throat  and  difficulty  in  swallowing.  I 
thought  that  this  was  at  least  highly  exaggerated,  and  ordered  ex- 
tract of  belladonna,  O'l  grammes  [gr.  jss.],  to  be  given  without  his 
knowledge  in  a  suppository.  The  next  day  he  complained  that  the 
suppository  had  produced  the  typical  effects  of  belladonna,  and  he 
reproached  me  for  having  imposed  on  him. 

Constipation  should  be  relieved  as  long  as  possible  by  mild 
vegetable  aperients.  The  various  salines  are  to  be  avoided,  since 
they  needlessly  weaken  the  patient  by  the  loss  of  fluid,  and  may 
easily  cause  diarrhoea.  Where  the  constipation  is  marked,  we  may 
use  cathartic  pills,  like  those  mentioned  under  dilatation  of  the 
stomach  (p.  154).  Where  faeces  have  accumulated  in  the  large 
intestines  enemata  are  indicated,  either  of  lukewarm  water  alone, 
or  with  laxative  agents,  like  glycerin  injections  which  may  be 
given  up  to  30  to  50  grammes  [  5  j  to  §  j  3  v],  and  glycerin  sup- 
positories ;  yet  all  these  fail  as  soon  as  there  is  a  general  paresis 
of  the  gut  and  an  accumulation  of  the  fseces  in  the  small  intes- 
tines. For  diarrhoea  we  may  use  opium  in  suppositories  or  in 
enemata.  There  is  no  indication  for  loading  the  stomach  with  the 
familiar  astringents — calumba,  hsematoxylon,  catechu,  nitrate  of 
silver,  tannim,  etc. — because  the  diarrhoeal  passages  are  due  to  such 
extensive  anatomical  lesions  that  the  mild  astringents  and  the  anti- 
catarrhal  remedies  are  absolutely  useless. 

In  the  section  on  dilatation  of  the  stomach  I  have  already  dis- 
cussed the  treatment  of  accumulation  and  decomposition  of  the 
stomach-contents  which  follow  the  stenosing  of  the  pylorus  by  a 
tumor. 

A  diet  of  starches  and  vegetables  is  more  easily  borne  than  one 


214  DISEASES   OP  THE  STOMACH. 

of  meat,  since  the  diminution  in  tlie  secretion  of  liydrocliloric 
acid  causes  the  digestion  of  albumen  and  meat  to  be  incomplete. 
In  most  cases  milk  is  also  poorly  borne  on  account  of  the  absence 
of  rennet,  and  not  even  the  addition  of  soda  or  lime-water,  which 
normally  stimulate  its  secretion,  will  be  of  any  service.  It  would 
be  better  to  add  a  few  drops  of  cognac  to  a  tablespoonful  of  milk. 
Kefir  and  peptonized  milk  are  relished.  The  other  artificial  food- 
products  are  also  indicated,  especially  the  meat-peptones  in  bouillon, 
soups,  sauces,  etc. ;  it  is  greatly  to  be  regretted  that  the  patients  tire 
so  soon  of  even  the  best  of  them  (Kemmerich's  or  Koch's  meat- 
peptones  and  Leube's  beef  solution) ;  in  my  own  ex23erience  I  found 
that  the  only  preparation  which  is  relished  for  a  longer  period  is 
the  meat-peptone  chocolate  and  peptone-beer  [see  Lecture  YIII]. 
The  otherwise  very  commendable  soups  of  leguminous  flour,  Nes- 
tle's  food,  and  the  like,  labor  under  the  same  disadvantage.  All 
kinds  of  food  should  be  cut  up  as  fine  as  possible,  or  should  be 
eaten  in  the  form  of  paps. 

For  many  patients  such  a  diet  of  paps  and  finely  divided  food  is 
a  veritable  torture.  The  muscles  of  mastication  and  the  salivary 
glands  feel  an  almost  irresistible  desire  to  be  once  more  in  action, 
and  the  palate  longs  for  a  hearty  and  delicious  morsel.  When  this 
condition  is  reached — usually  it  is  about  the  middle  of  the  course  of 
the  disease — it  is  pardonable  if  the  rules  are  somewhat  relaxed  and 
the  patient  allowed  to  satisfy  his  longings,  unless,  of  course,  such  an 
allowance  is  positively  injurious.  This  course  is  the  more  justifi- 
able as  the  end  of  the  disease  is  marked  by  complete  anorexia. 
After  all,  we  usually  deal  with  people  Avhose  main  desire  has  been  a 
well- su j)plied  table,  and  such  a  relaxation  afi^ords  them  the  last  pleas- 
ure of  their  lives  ! 

There  is,  at  least,  one  group  of  foods  which  must  always  be 
avoided,  namely,  those  inclosed  in  tough  envelopes,  which  not  even 
cooking  will  soften,  or  which  are  permeated  by  bundles  of  dense 
connective  tissue,  enabling  them  to  resist  the  action  of  the  digestive 
juices  for  a  long  time.  To  this  group  must  also  be  added  the  fer- 
mented liquors  containing  a  large  percentage  of  fermentable  sub- 
stances, and  also  the  fats  whose  prolonged  stay  in  the  stomach  causes 
them  to  decompose  and  thus  cause  trouble.     There  are  other  foods 


NON-CANCEROUS  TUMORS   OF   STOMACH.  215 

wliicli  may  be  allowed,  but  wliicli  are  very  differently  borne  by  in- 
dividual patients.  Here  the  personal  experience  of  the  patient  is 
the  best  guide.  Furthermore,  the  anxious  sufferer  may  be  placed 
in  a  dilemma  by  one  physician  allowing  what  another  has  forbidden. 
If  we  do  not  know  what  has  already  been  recommended,  it  is  well 
not  to  give  a  definite  bill  of  fare,  but  to  follow  Trousseau's  advice, 
to  refer  the  patient  to  his  own  experience. 

All  of  the  above  refers  only  to  the  first  stage  of  the  disease, 
when  the  so-called  dyspeptic  symptoms  constitute  the  chief  part  of 
the  clinical  picture.  Later,  the  choice  of  food  becomes  more  and 
more  restricted,  till  finally  it  is  limited  to  thin  broths  (flour,  rice, 
sago,  and  tapioca),  with  the  addition  of  peptones,  finely  scraped 
white  meat,  jellies  of  rice  and  calves'  feet,  eggs  (if  they  can  be  di- 
gested), bouillon,  and  the  like.  Bouillon  is  usually  rejected  very 
soon.  The  patient's  strength  is  to  be  maintained  by  stimulating 
beverages  like  strong  teas,  good  clarets,  the  so-called  dessert  wines 
(except  port,  which  is  too  highly  sweetened),  and  finally  champagne. 

Treatment  at  the  mineral  springs,  or  the  home  consumption  of 
these  waters,  is  naturally  useless  after  the  diagnosis  has  once  been 
positively  made.  But  the  disease  is  easily  and  frequently  mistaken 
in  its  early  stages,  and  the  patient  on  his  own  or  his  physician's  ad- 
vice goes  to  one  of  the  celebrated  spas  like  Carlsbad,  Marienbad, 
Ems,  Vichy,  etc.,  to  cure  his  "chronic  stomach  catarrh."  Then 
later  on  we  hear  the  familiar  reproach  against  the  doctor  "  who  sent 
me  to  the  wrong  spring."  This  condition  of  things  will  be  im- 
proved in  the  future  when  the  chemical  diagnostic  aids  will  be  more 
generally  employed,  and  thus  enable  us  to  have  at  least  a  suspicion 
early  in  the  disease,  and  to  act  accordingly.  Many  patients,  without 
knowing  what  their  true  condition  is,  insist  on  going  to  some  spring. 
"  I  then  permit  them  to  carefully  take  small  quantities  of  the  cor- 
responding water  at  home,"  says  Lebert,  "  and  as  they  usually  de- 
rive no  benefit  from  it,  they  soon  renounce  the  trip  to  the  spring 
itself." 

[The  Non-cancerous  Tumors  of  the  Stomach. — Concerning  these 
little  need  be  said,  for  "  they  are  comparatively  rare  and  are  usually 
unattended  by  [special]  symptoms.  Even  should  a  tumor  be  discov- 
ered, there  are  no  means  of  determining  the  nature  of  the  tumor ; 


21G  DISEASES  OP  THE  STOMACH. 

and,  if  symptoms  are  produced  by  tlie  tumor,  tlie  case  will  probably 
be  diagnosticated  as  one  of  cancer."  * 

These  tumors  may  be  benign  or  malignant — primary  or  secondary. 
They  include  paj)illomata,  fibromata,  lipomata,  myomata,  lymphom- 
ata,  adenomata,  sarcomata  (see  page  205),  myo-sarcomata,  and  lymplio- 
sarcomata.  Cysts  may  also  be  found.  Foreign  bodies,  especially 
balls  of  hair  (see  page  199)  and  gastroliths,  may  simulate  tumors.] 

*  [Welch.  Log.  cit.,  p.  578.  In  addition  to  eases  reported  there,  see  P.  Albertoni. 
Ri vista  clinica  e  terapeutica.  Naples,  lSrovember'12,  1889. — Kunze,  Arch,  fiir  klin. 
Chirurgie,  Bd.  xl,  Heft  3. — Malvoz.  Annales  de  la  Societ.  med.  chir.  Liege,  Au- 
gust and  September,  1889. — Tr,] 


LECTUKE   VL 

ULCER   OF   THE    STOMACH ULCUS    PEPTICUM    SEU   EODENS. 

Gentlemen  :  Tlie  s]3ecimen  wliich  I  here  show  you  was  removed 
from  the  following — in  many  respects — remarkable  case  : 

The  patient,  aged  tliirty-five,  was  a  married  man,  father  of  two  healthy 
children,  an  architect  hy  profession,  whose  work  had  of  late  fallen  off, 
and  who  was  subjected  to  much  excitement  and  worry.  From  his  youth 
he  had  shown  a  tendency  to  embonpoint;  he  was  a  hearty  eater,  and  a 
still  heartier  drinker  of  Bavarian  beer.  He  never  had  syphilis,  and  had 
always  been  in  good  health.  For  the  past  year  he  had  now  and  then 
complained  of  pain  in  the  abdomen,  as  a  rule  not  localized,  and  only  occa- 
sionally referred  to  the  right  side.  At  times  he  was  somewhat  irritable, 
and  suffered  from  insomnia.  In  spite  of  good  care  he  lost  flesh  constantly 
— about  eighty-eight  pounds  during  the  past  year  ;  his  weight  was  re- 
duced from  204  to  116  pounds.  This  was  so  conspicuous  as  to  cause  him 
anxiety.  His  occasional  attacks  of  abdominal  pain  were  ascribed  by  his 
relatives  to  all  manner  of  secret  dietetic  errors. 

On  examination  with  my  colleague,  Dr.  G.,  no  abnormalities  either  in 
the  nervous  system  or  in  the  organs  of  vegetative  life  could  objectively  be 
discovered,  with  the  exception  of  slight  pain  on  deep  pressure  in  the  prae- 
cordium,  such  as  is  present  in  all  cases  of  gastric  catarrh.  Appetite  good, 
tongue  clean,  bowels  irregular,  but  easily  regulated  by  a  mild  cathartic. 
There  was  frequent  flatulence.  His  general  condition  was  feeble ;  he  was 
languid,  and  had  lost  all  interest  in  his  work.     The  urine  was  normal. 

In  view  of  the  great  loss  of  weight,  we  could  not  be  satisfied  with  the 
idea  that  this  was  a  case  of  simple  catarrh  of  the  digestive  tract,  which 
was  the  opinion  of  others,  and  we  consequently  concluded  to  observe  the 
patient  while  under  a  strict  diet.  For  this  purpose  he  was  admitted  to  the 
sanitarium,  and  placed  upon  a  nourishing  but  somewhat  restricted  diet. 
During  the  first  few  days  infusion  of  rhubarb  was  given,  with  a  prompt 
result.  Examination  of  the  expressed  stomach-contents,  after  a  test-break- 
fast, revealed  a  normal  quantity  of  hydrochloric  acid,  peptone,  and  achro- 
odextrin — no  granulose.  On  the  whole  he  felt  well,  complaining  only  of 
transient  lack  of  sleep  and  pain  in  the  limbs,  ascribed  to  the  unaccus- 
tomed confinement  to  his  room  and  to  the  fact  that  he  was  only  permitted 
to  be  up  two  hours  daily.  In  spite  of  this  the  loss  of  weight  continued, 
amounting  to  half  a  pound  duinng  the  first  week  and  three  quarters  of  a 
pound  during  the  second.     On  the  sixteenth  day  he  insisted  on  going  out 


218  DISEASES  OF    THE  STOMACH. 

to  attend  to  some  business  matter.  This  he  did  during  the  morning  in 
company  with  his  wife,  and  while  gone  he  positively  committed  no  error 
in  diet.  In  the  course  of  the  afternoon  he  suddenly  became  very  restless, 
rang  the  bell  rei^eatedly,  and  always  a  number  of  times  in  succession,  for 
the  servant  to  get  him  this  or  that  trifle.  Suddenly,  without  any  nau- 
sea, vomited  about  one  litre  [quart]  of  fresh,  bright-red  blood  mixed  with 
a  little  mucus.  The  indicated  medication  (ergot,  morphine,  cold  local  ap- 
plications, and  swallowing  small  pieces  of  ice)  was  at  once  exhibited,  and 
he  passed  the  night  without  any  further  attack.  The  next  morning  he 
had  two  fresh  hsemora-hages,  preceded  by  excitement,  and  in  the  coiirse  of 
the  day  seven  bloody  stools — at  first  dark-brown,  fairly  hard  masses,  then 
tarry  evacuations,  and  finally  nearly  pure  blood.  He  became  intensely 
anaemic,  so  that  the  question  of  transfusion  was  considered,  but  the  pulse 
rallied,  and  the  patient  passed  a  good  night.  On  the  following  day  he 
was  in  a  comparatively  good  condition,  so  that  he  could  see  his  wife  and 
father.  Nevertheless,  I  was  called  to  see  him  the  next  night,  because  he 
had  suddenly  fallen  into  a  comatose  condition.  He  is  said  to  have  con- 
versed at  eleven  o'clock,  and  to  have  assured  the  house-physician  that  he 
felt  well.  At  two  o'clock  I  found  the  patient  fully  unconscious,  with 
faint  conjunctival  reflex,  small,  wiry  pulse,  retracted  abdomen,  cold  skin, 
and  well-marked  Cheyne-Stokes  respiration.  He  had  several  passages  of 
bloody  intestinal  contents,  and  died  at  5  A.  M. 

He  received  in  all  2  grammes  [gr.  xxx]  of  the  extract  of  ergot  subcu- 
taneously,  and  about  50  milligrammes  [gr.  |]  of  morphine  and  opium, 
partly  hypodermically  and  partly  in  sui)positories.  Considering  all  that 
had  taken  place,  no  doubt  could  exist  that  the  diagnosis  was  ulcer,  with 
haemorrhage.  Its  site,  however,  whether  it  was  in  the  stomach  or  in  the 
duodenum,  remained  questionable,  as  also  the  cause  of  the  final  catas- 
trophe. Had  there  been  a  perforation,  or  did  a  complication  arise  in  the 
form  of  cerebral  apoplexy  ?  The  soporific  condition  and  the  tj^pe  of  respi- 
ration most  frequently,  if  not  exclusively,  seen  in  injuries  of  the  brain 
seemed  to  point  to  the  latter,  while,  opi)Osed  to  the  former,  was  the  absence 
of  air  in  the  abdomen,  as  well  as  the  manifestly  slight  sensitiveness  of  the 
abdominal  walls. 

The  autopsy  gave  the  following  results  (Fig.  25) : 

Abdominal  walls  moderately  tense  and  vaulted.  On  opening  the  ab- 
dominal cavity  some  air  escaped.  In  the  abdomen  was  a  considerable 
quantity  of  fresh  blood.  The  coils  of  intestine  were  somewhat  flabby,  the 
serosa  moderately  injected.  In  the  center  of  the  anterior  wall  of  the 
stomach  was  found  a  rectangular  perforation  about  the  size  of  a  bean 
with  blackish,  bloody  margins.  The  serous  coat  of  the  stomach  was  dotted 
with  numerous  small  greenish  points.  There  were  five  losses  of  substance 
in  the  stomach,  varying  in  size  and  depth ;  the  largest  was  situated  mid- 
way between  the  pyloric  and  cardiac  ends,  the  others  in  the  lower  third 
of  the  stomach.  The  large  ulcer  was  almost  rectangular  in  shape,  4"2 
centimetres  [l^g  inch]  in  length  by  2  centimetres  [4  inch]  in  w4dth.  It 
extended  to  the  serous  coat,  and  toward  the  pylorus  showed  the  above- 
mentioned  perforation,  which  was  divided  in  half  by  a  thin,  thread-like 
bridsre  of  serous  membrane.     In  the  center  of  the  base  of  the  ulcer  the 


Fig.  25. — Perforating  ulcer  of  stomach,     c,  cardia  ;  j9,  pylorus  ;  -m,  perforating  ulcer. 

(219) 


220  DISEASES  OF  THE  STOMACH. 

serous  coat  was  somewhat  thicker,  hecoming  thin  again,  and  also  trans- 
parent like  tissue-paper,  toward  the  cardiac  end.  At  this  situation  there 
was  a  thrombosed  and  very  tortuous  vessel,  about  the  diameter  of  a  pin, 
from  which  the  fatal  haemorrhage  arose.  The  margins  of  the  ulcer  in  the 
lower  and  middle  portions  were  thickened,  wall-like,  and  undermined ; 
in  the  upper  portion  they  ran  gradually  into  the  intact  mucous  mem- 
brane. 

The  other  ulcers  extended  only  to  the  muscular  layer,  or  were  limited 
to  the  mucous  membrane.  In  one  of  these  the  remains  of  a  small  throm- 
bosed vessel  could  be  observed.  The  rest  of  the  mucous  membrane  was 
in  the  usual  condition,  except  that  the  small  greenish  points  described 
above  as  appearing  on  the  serous  coat  were  also  seen  here.  The  micro- 
scope revealed  a  catarrhal  condition  in  the  fundus  and  pylorus,  with 
marked  cellular  infiltration  and  cloudy  glandular  cells.  The  "green 
points  "  were  not  due  to  extravasations  of  blood,  but  were  produced  by  the 
vessels  of  the  submucosa,  which  were  uncommonly  enlarged  and  mark- 
edly tortuous,  and  especially  by  the  veins,  which  were  widely  distended 
with  blood.  There  was  no  amyloid  degeneration.  In  the  intestines  were 
found  large  quantities  of  thin  fluid  blood.  The  remaining  abdominal  vis- 
cera were  normal,  but  anaemic  to  a  high  degree. 

This  case  presents  several  deviations  from  the  common  type  of 
gastric  ulcer,  not  only  in  regard  to  the  course  of  the  disease,  or 
rather  its  latency,  but  also  on  account  of  the  not  very  common  form 
of  the  ulcer  and  the  perforation,  and  finally  in  the  uncommon  mani- 
festations to  which  the  perforation  itself  gave  rise.  I  will  return  to 
this  later  on. 

I  shall  now  describe  the  clinical  picture  of  the  so-called  round, 
but  better  named  chronic  eroding  gastric  ulcer,  in  contradistinction 
to  the  acute  ulcers  produced  by  the  action  of  corrosive  poisons, 
which,  as  they  do  not  belong  here,  will  be  discussed  in  speaking  of 
toxic  gastritis  [see  Lecture  YII].  The  name  chronic  round  gastric 
ulcer  is  also  not  quite  proper,  inasmuch  as  it  is  occasionally  acute  or 
subacute,  and  as  it  is  by  no  means  always  round,  but  frequently  of 
various  forms. 

Etiology. — Investigators  have  zealously  endeavored  both  clini- 
cally and  experimentally  to  establish  the  causes  of  gastric  ulcer. 
Synchronous  with  the  commencement  of  the  experimental  era  in 
medicine  is  the  first  careful  and  comjDrehensive  description  of  this 
affection  by  Cruveilhier,  who  was  the  first  to  raise  the  gastric  ulcer 
from  a  curiosity  of  the  autopsy-table  to  the  dignity  of  a  definite  and 
recognizable  pathological  condition. 


ETIOLOGY  OP  GASTRIC   ULCER.  221 

Experiments  on  Animals. — Gastric  ulcers — tliat  is,  circumscribed 
losses  of  tissue  in  the  mucous  membi-ane,  extending  to  tlie  submu- 
cous and  muscular  layers — may  be  produced  in  animals  by  various 
means,  wliicli  in  the  end  always  amount  to  a  local  disturbance  of 
nutrition  in  limited  portions  of  the  mucous  membrane,  lasting  a  cer- 
tain time.  There  is  either  a  shutting  off  of  circumscribed  vascular 
areas  with  consequent  necrosis  and  sloughing  of  the  tissues,  the 
gastric  juice  meanwhile  attacking  the  spots  deprived  of  their  nor- 
mal nourishment  exactly  as,  under  favorable  conditions,  it  causes 
softening  (digestion)  of  the  dead  stomach,  but  to  a  greater  degree. 
This  is  due  to  emboli  artificially  produced,  ligation  of  small  vessels, 
or  to  haemorrhages  which  result  from  injury  to  certain  portions  of 
the  central  nervous  system.  Or,  the  ulcer  may  be  referred  to  direct 
mechanical,  chemical,  or  thermal  lesions  of  the  mucous  membrane, 
the  latter  being  at  the  same  time  accompanied  by  an  alteration  of 
the  circulation  in  the  parts  subjected  to  irritation.  But  these  losses 
of  substance  heal  with  exceptional  rapidity,  cicatrization  advancing 
from  the  margins  to  the  center  with  restoration  of  the  mucous 
membrane.  According  to  the  investigations  of  Griffini  and  Yas- 
sale,*  the  mucous  membrane  of  the  fundus  of  the  stomach  is  replaced 
by  the  formation  of  true  peptic  glands  from  the  superficial  epi- 
thelium which  at  first  covers  the  wound,  this  in  turn  being  formed 
from  the  glandular  epithelium  found  in  the  glands  situated  in  the 
margins  of  the  wound.  This  replacement,  too,  is  prompt  and  effi- 
cient, so  that  in  the  very  late  stages  of  the  process  it  is  difficult  to 
find  the  situation  of  the  injury,  while  after  ten  to  fifteen  days  it 
has  entirely  healed,  without  leaving  behind  a  trace  of  its  presence. 
Thus,  these  are  fundamentally  acute  defects  of  the  mucous  membrane 
which  can  not  properly  be  called  ulcers ;  for  these,  at  least  during  some 
portion  of  their  existence,  must  display  the  tendency  to  spread.  For 
the  production  of  chronic  ulcers  another  force  must  come  into  play — 
namely,  a  disproportion  must  exist  or  be  created  between  the  secre- 
tion of  the  gastric  glands  and  the  nutritive  blood,  either  synchronous 
with  or  previous  to  the  appearance  of  the  local  lesion ;  it  may  be 

*  L.  Griffmi  unci  G.  Vassale.  L^eber  die  Reproduction  der  Magenschleimhaut, 
Beitrage  ziir  pathologischen  Anatomic,  etc.,  von  Ziegler  und  IS'auwerck,  Bd.  3. 
Heft  5,  S.  425. 


222  DISEASES  OP  THE  STOMACH. 

either  an  increased  acidity  of  the  former  or  a  deterioration  of  the 
latter,  or  both  factors  may  be  present  at  the  same  time.  Ebstein,* 
making  use  of  a  discovery  of  SchifE,  produced  gastric  haemorrhages 
and  corroding  ulcers,  and  even  perforation,  by  injury  to  the  anterior 
corpora  quadrigemina.  We  may  well  assume  that  an  excessive  pro- 
duction of  acid  secretion  took  place  here,  perhaps  due  to  the  cere- 
bral irritation.  Koch  and  Ewald,f  by  introducing  a  hyperacid,  0"5- 
per-cent,  solution  of  hydrochloric  acid,  produced  deep  ulcers  in  the 
stomachs  of  animals  in  which  gastric  haemorrhages  had  been  caused 
by  section  of  the  spinal  cord,  according  to  SchifE's  method.  Quincke 
and  Daettwyler :{:  made  the  animals  anaemic  by  venesection.  Silber- 
mann  *  caused  haemoglobinaemia  by  means  of  substances  which  dis- 
integrate the  blood-corpuscles.  Under  such  circumstances  the  losses 
of  substance  produced  by  the  above-mentioned  methods  heal  but 
gradually  and  tardily,  or  they  may  go  on  even  to  perforation,  as 
occurred  in  one  of  Silbermann's  experiments.  Then  only  have  the 
experiments  on  animals  borne  any  analogy  to  the  clinical  picture  of 
gastric  ulcer.  Tolma  |  succeeded  in  producing  softening  of  the 
stomach  as  well  as  typical  gastric  ulcers  in  rabbits  and  dogs  by  ligat- 
ing  the  stomach  above  and  below — that  is,  tying  the  oesophagus  just 
above  the  cardia,  and  the  duodenum  between  the  pylorus  and  the 
mouth  of  the  common  bile-duct.  The  result  of  this  was  a  stagnation 
and  fermentation  of  the  contents  of  the  stomach,  the  quantity  of  the 
latter  being  more  or  less  increased  by  the  persistent  secretion  of  the 
gastric  juice.  In  this  way  the  walls  of  the  stomach  were  rendered 
so  tense  that  sharply  localized  hsemorrhagic  infarctions  were  pro- 
duced, and  from  these  typical  gastric  ulcers.  Tolma  also  concludes 
that  "  a  disturbance  of  nutrition  must  precede  the  ulceration,  be  it 


*  W.  Ebstein.  Experiinentelle  Untersuchungen  iiber  das  Znstandekommen  der 
Blutextravasate  in  der  Magenschleinhaut.     Arch,  fiir  exper.  Pathol.,  Bd.  2,  S.  183. 

f  Ewald.  Klinik,  etc.,  I.  Theil.,  3.  Aufl.,  S.  123.  I  must  say  that  we  did  not 
carry  on  our  experiments  in  the  above  sense,  although  they  correspond  entirely  with 
them. 

X  H.  Quincke  und  Daettwyler.  Correspondenzbl.  f.  Schweizer  Aerzte,  1875, 
S.  101. 

*  0.  Silbermann.  Experimentelles  und  Kritisches  zur  Lehre  vom  Ulcus  ven- 
triculi  rotund.     Deutsche  med.  Wochenschr.,  1886,  Xo.  29,  S.  497. 

II  Tolma.  Untersuchungen  iiber  Ulcus  ventriculi  simplex,  Gastromalacie  und 
Ileus.    Zeitschr.  fiir  klin.  Med.,  Bd.  xvii,  S.  10. 


ETIOLOGY   OF   GASTRIC    ULCER.  223 

either  a  simple  angemia  or  a  retardation  in  the  movement  of  the 
nutritive  Ijmph  ;  or,  finally,  more  profound  changes  in  tlie  tissues 
themselves." 

In  man,  too,  if  we  confine  ourselves  to  the  typical  ulcer  of  the 
stomach,  and  disregard  the  secondary  ulceration  of  carcinoma  or  of 
phlegmonous  gastritis,  we  have  to  record  a  twofold  course  of  gastric 
ulcer.  Constant  reference  is  made  to  the  fact  that  it  is  doubtlessly 
not  uncommon  for  ulcers  to  occur — that  is,  in  the  sense  of  the  de- 
fects of  the  mucous  membrane  described  above — -which  never  reach 
the  point  of  manifesting  themselves  clinically,  or  which  do  not  j^re- 
sent  the  typical  picture  of  ulcer  of  the  stomach,  but  which  give  rise 
only  to  indefinite  symptoms,  which  do  not  spread  and  which  do  not 
really  cicatrize.  To  this  category  belong  the  hsemorrhagic  erosions 
of  Eokitansky,  which  were  already  regarded  by  him  as  the  initial 
steps  leading  to  true  gastric  ulcer.*  Here  I  might  also  include  the 
so-called  follicular  ulcers,  which  are  due  to  the  swelling  and  con- 
secutive suppuration  of  the  glandular  follicles.  The  factors  enu- 
merated above  often  give  rise  to  such  processes,  "We  need  only 
think  of  the  frequent  occurrence  of  circumscribed  haemorrhages 
from  the  mucous  membrane  in  chronic  catarrh,  especially  in  drink- 
ers ;  of  the  irritations  of  the  mucous  membrane  caused  by  too  hot 
ingesta,  and  of  the  artificial  lesions  produced  in  this  membrane  by 
the  introduction  of  sounds,  to  have  a  full  quota  of  such  factors.  In 
proof  of  this — the  transient  haemorrhages  and  follicular  suppuration 
due  to  irritating  ingesta — we  possess  a  classical  witness  for  all  time 
in  the  Canadian  experimented  on  by  Beaumont.f  Is  it  to  be  ex- 
pected in  the  many  cases  in  which  sharp  objects,  such  as  splinters 


*  C.  V.  Rokitansky.     Lehrbuch  der  pathol.  Anatomie,  3.  Aufl. 

f  W.  Beaumont.  Experiments  and  Observations  on  the  Gastric  Juice  and  the 
Physiology  of  Digestion.  Boston,  1833,  p.  108.  The  passage  in  these  excellent  in- 
vestigations, referred  to,  reads  as  follows  :  "  There  are  sometimes  found  on  the  in- 
ternal coat  of  the  stomach  (especially  after  irritation  of  the  mucosa  by  food)  erup- 
tions, or  deep  red  pimples :  not  numerous,  but  distributed  here  and  there  upon  the 
villous  membrane,  rising  above  the  surface  of  the  mucous  coat.  These  are  at  first 
sharp  pointed  and  red,  but  frequently  become  filled  with  white  purulent  matter. 
At  other  times  irregular  circumscribed  red  patches,  varying  in  size  and  extent  from 
half  an  inch  to  one  and  a  half  inches,  are  found  on  the  internal  coat.  These  appear 
to  be  the  effect  of  congestion  in  the  minute  blood-vessels  of  the  stomach.  There 
are  also  seen  at  times  small  aphthous  crusts  in  connection  with  these  red  patches." 


224  DISEASES  OP  THE  STOMACH. 

of  bone,  knife  and  dagger  blades,  etc.,  are  accidentally  or  purposely 
swallowed,  that  tliey  will  always  pass  off  without  lesion  to  the  wall 
of  the  stomach  ?  And  yet  ulcers  of  the  stomach  are  among  the 
rarer  results.  One  of  the  most  remarkable  examples  of  this  kind 
and  at  the  same  time  a  most  striking  proof  of  what  the  stomach 
may  be  subjected  to,  is  the  following  very  curious  case  of  the  sailor, 
John  Gumming,  reported  by  Dr.  Marcet :  * 

In  the  year  1799  an  American  sailor  saw  a  juggler  in  Havre  perforra 
the  trick  of  knife-swaUowing.  Eeturning  to  his  vessel  somewhat  intoxi- 
cated, he  was  foolhardy  enough  to  try  to  swallow  his  open  pocket-knife, 
and,  succeeding  in  this,  he  "  ate  "  tln^ee  more.  Three  passed  oflP  in  the 
stool  during  the  next  few  days,  but  one  disappeared  forever.  One  even- 
ing, six  years  later,  he  again  swallowed  portions  of  six  knives,  but  this 
time  not  without  unpleasant  though  very  transient  results,  on  account  of 
which  he  was  admitted  to  a  hospital.  He  did  this  frequently,  till  he  had 
swallowed  about  thirty-five  knives.  Finally,  he  was  taken  seriously  ill, 
and  he  died  in  Guy's  Hospital,  in  London,  in  1809.  In  the  stomach  some 
thirty  pieces  of  blades,  in  parts  markedly  corroded,  together  with  handles, 
were  found  ;  two  blades  in  the  colon  and  rectum,  which  were  placed  trans- 
versely and  had  perforated  the  intestinal  wall  (and  that  without  causing 
peritonitis ! ),  but  no  recent  or  old  ulcers  of  the  stomach,  or  any  remains 
of  them. 

It  is  inconceivable  that  the  man's  repeated  onslaughts  on  the  mu- 
cous membrane  of  his  stomach  should  have  passed  off  without  pro- 
ducing any  lesion  at  all ;  yet  he  nevertheless  acquired  no  gastric 
ulcer.  Moreover,  it  is  also  recorded  that  to  the  end  he  always  en- 
joyed good  health,  and  that  he  had  a  very  good  appetite. 

If,  therefore,  gastric  ulcer  always  resulted  from  the  injuries 
above  mentioned,  it  would  appear  much  more  frequently  than  is  ob- 
served ;  in  fact,  it  would  be  the  rule,  and  its  absence  the  exception. 
Let  us  take,  for  instance,  the  frequently  mentioned  occurrence  of 
ulcer  in  cooks.  It  is  true  that  their  employment  affords  them  ample 
opportunity  to  swallow  hot  morsels.  But,  not  to  speak  of  cooks, 
how  many  persons  eat  their  food  hastily,  and  as  hot  as  possible, 
without  acquiring  gastric  ulcer ;  and  how  small  is  the  percentage  of 
cooks  who  suffer  with  ulcer  in  comparison  to  the  entire  number 
of  the  members  of  this  honorable  craft !  On  the  other  hand,  we 
actually  know  of  cases  in  which  ulcers  were  due  to  traumatisms. 

*  Marcet.    Med.-Chirurg.  Transactions,  vol.  xii,  p.  73. 


ETIOLOGY  OF  GASTRIC   ULCER.  225 

Thus  Yanni  *  reports  the  case  of  a  woman,  thirty-two  years  of  age, 
in  whom  all  the  symptoms  of  a  typical  gastric  ulcer  developed  im- 
mediately after  a  blow  in  the  epigastrium.  The  same  author  has 
collected  fourteen  reported  cases  of  round  ulcer  of  traumatic  origin. 
In  this  category  we  may  also  include  the  cases  described  by  Tolma,f 
in  which  haemorrhages  of  the  stomach  and  ulceration  resulted  from 
severe  general  convulsions. 

Changes  in  the  Blood. — Evidently  here,  as  well  as  above,  there 
must  be  a  second  factor  in  order  to  render  possible  the  chronic  de- 
velopment of  the  supposed  injury  and  its  secpielse — a  factor  which, 
to  a  certain  extent,  forms  the  basis  on  which  the  ulcer  can  kut 
i^o^hv  develop.  And  it  is  only  by  means  of  such  a  permanent  or 
transient  "  predisposition  "  that  the  much-discussed  question,  why 
some  ulcers  heal  and  others  progress,  can  be  solved.  There  is  no 
lack  of  analogies  for  such  a  condition.  I  need  only  bring  forward 
the  example  of  the  tubercle  bacilli  which  is  now  so  familiar  to  all. 
Here,  too,  there  is  the  exciting  poison,  the  bacillus,  to  which  num- 
berless persons  are  exposed  on  countless  occasions.  However,  to 
become  tuberculous,  the  predisposition  is  requisite,  which  fortu- 
nately is  not  the  possession  of  everybody.  In  man  this  predisposi- 
tion to  gastric  ulcer  resides  also  in  the  disproportion  existing  be- 
tween the  composition  of  the  gastric  juice  and  the  blood,  as  we 
have  already  recognized  it  as  necessary  for  the  artificial  production 
of  chronic  ulcer  of  the  stomach  in  animals.  It  is  not  the  alkalinity 
of  the  blood  which  prevents  the  auto-digestion  of  the  gastric  mucous 
membrane  and  the  subsequent  development  of  a  round  ulcer,  as 
stated  by  Pavy ;}:  in  his  explanation  at  that  time,  which,  deceptive 
by  its  simplicity,  was  therefore  almost  universally  accepted  ;  for  the 
old  teaching  that  the  alkaline  condition  of  the  deeper  layers  of  the 
gastric  mucous  membrane  prevents  its  digestion  by  the  gastric  juice 
under  normal  conditions  is  untenable.  Disregarding  the  fact  that 
this  does  not  explain  why  the  upper  layers  of  the  mucosa  (which, 
as  is  well  known,  have  an  acid  reaction)  are  not  digested,  Edinger 

*  Vanni.    Sull'  ulcera  dello  storaaco  d'  origine  traumatico.     Lo  Sperimentale. 
Juglio,  1889. 
■f-  Loc.  cit. 
X  Pavy.     On  Gastric  Erosion.     Guy's  Hosp.  Reports,  xiv,  1868. 


226  DISEASES  OF  THE  STOMACH. 

has  endeavored  to  prove  that  the  deeper  layers  are  also  acid,*  And 
even  if  we  are  unwilling  to  ascribe  much  weight  to  these  experiments, 
as  I  have  proved  in  the  place  cited  below,  it  is  nevertheless  true  that 
the  alkaline  reaction,  as  such,  does  not  suffice  here — alkali  albumi- 
nates are  also  digested — because  the  blood  may  be  made  neutral  by 
means  of  acid,  as  Samuelson  f  has  shown,  and  yet  not  lead  to  auto- 
digestion  of  the  stomach. 

This  investigator  gives  still  more  important  reasons,  and  refers 
especially  to  the  contradiction  that  the  acid  formed  in  the  glands  is 
not  neutralized  when  it  enters  the  cavity  of  the  stomach,  but  that 
this  is  supposed  to  occur  when  the  reverse  takes  place — i.  e.,  when 
the  acid  is  brought  in  contact  with  the  mucous  membrane.  There- 
fore, either  no  free  alkali  exists  in  the  neighborhood  of  the  acid,  or 
it  can  no  more  neutralize  the  excreted  than  it  can  the  penetrating 
acid.  Furthermore,  Sehrwald :{;  has  shown  that  in  a  living  animal 
the  diffusion  of  an  alkali  through  the  wall  of  the  stomach  into  an 
acid  solution  which  had  been  poured  into  its  cavity  proceeds  far 
differently  than  in  a  stomach  removed  from  the  body,  taking  place 
much  more  energetically  in  the  latter  than  in  the  former  case.  This 
is  a  remarkable  phenomenon,  which  can  only  be  explained  by  the 
influence  of  the  living  cell  on  the  course  of  the  physical  process. 
Further,  how  is  it  that  an  ulcer  heals  in  spite  of  the  damage  done  to 
the  protecting  network  of  vessels?  Why,  for  instance,  does  not  the 
pancreas  digest  itself?  This  problem  still  lies  before  us,  for  our 
knowledge  of  the  zymogens  *  can  not  solve  it,  and  we  are  no  nearer 
the  solution  even  after  recognizing  "  the  vital  energy  of  the  cells  " 
or  Hunter's  "  living  principle." 

"We  must  cling  to  the  fact  that  normal  gastric  juice  and  normal 
blood  do  not  cause  the  formation  of  an  ulcer  from  the  factors  already 
discussed,  nor  do  they  further  its  course  or  prevent  its  healing.  The 
disproportion  between   the   acidity  of   the   gastric   juice   and   the 

*Edinger.  Ueber  die  Reaction  der  iebenden  Magenschleimhaut.  Pfliiger's 
Archiv.,  Bd.  xxix,  S.  247.     See  Ewald.     Kliriik,  etc.,  I.  Tlieil,  3.  Aufl.,  S.  121. 

f  Samuelson.  Die  Selbstverdauung  des  Magens.  Preyer's  Sammlung  physiol. 
Abhandl.,  1879.     II.  Reihe,  Heft  6. 

X^.  Sehrwald.  Was  verhindert  die  Selbstverdauung  das  Iebenden  Magens? 
Miinchener  med.  Wochenschr.,  1888,  No.  44  u.  45. 

«  Ewald.     Klinik,  etc.     I.  Theil,  3.  Aufl.,  S.  95. 


ETIOLOGY  OF  GASTRIC  ULCER.  227 

composition  of  tlie  blood  is  always  necessary  to  produce  such  a 
result. 

Leube  *  has  already  stated  that  "  in  chronic  gastric  ulcer  we  inust 
assume  the  coincident  appearance  of  two  causes  of  corrosion,  ansemia 
and  an  occasional  abnormal  acidity  of  the  gastric  juice  "  ;  but,  as 
Pavy  did  in  his  time,  he  discusses  the  question  at  great  length 
whether  diminished  alkalinity  or  increased  acidity  can  alone  cause 
an  ulcer.  According  to  my  conception,  however,  these  factors  are 
merely  adjuvants,  and  we  must  deal  not  so  onuch  with  the  alka- 
linity of  the  hlood,  hut  rather  with  its  altered  composition  and  the 
restdting  insufficient  nourishment  of  the  cells. 

Cohnheim,f  who  was  a  firm  believer  in  the  theory  of  alkalinity, 
thought  that  tumors  in  the  stomach  were  not  digested  by  the  gastric 
juice  because  they  were  very  vascular,  and  hence  were  correspond- 
ingly strongly  alkaline.  We  know,  however,  that  in  malignant 
tumors  the  digestive  power  of  the  secretion  is  markedly  diminished, 
and  that,  on  the  other  hand,  many  tumors,  in  spite  of  beiug  richly 
supplied  with  blood-vessels,  ulcerate  (that  is,  undergo  digestion) ; 
and  it  is  owing  to  this,  and  from  these  same  vessels,  that  haemor- 
rhages occur.  Just  here,  where  one  would  suppose  that  the  greatest 
possibility  existed  for  the  neutralization  of  the  gastric  juice,  its  cor- 
rosive action  comes  into  play  and  thereby  disproves  Cohnheim's 
argument,  which  at  first  sight  seems  very  plausible. 

Modern  Views. — The  exact  grounds  for  the  view  proposed  above 
have,  it  is  trule,  been  arrived  at  only  by  the  more  recent  investiga- 
tions. We  have  known  for  a  long  time  that  corroding  gastric  ulcers 
arise  from  anomalies  in  the  composition  of  the  blood.  Suppression 
of  the  menses,  chlorosis,  anaemia  after  parturition,  are  seen  too  fre- 
quently in  connection  with  gastric  ulcer  to  admit  of  any  doubt  as  to 
their  etiological  relations.  Indeed,  Miquel  %  reports  cases  in  which 
menstruation  at  first  ceased  and  then  returned  again ;  but  a  reap- 
pearance of  the  gastralgia  with  increased  severity  was  noticed  at 
every  menstrual  epoch.    Crisp,*  in  his  time,  collected  fourteen  cases 


*0.  Leube.    Die  Krankheiten  des  Magens,  3.  Aufl.,  1878,  S.  98. 
t  Colmheim.     Allgemeine  Pathologie. 
t  Miquel.     Hannover.  Zeitschr.  f.  prakt.  Heilkunde. 
*  Crisp.     On  Perforation  of  the  Stomach.     Lancet,  August  5,  1843. 
35 


228  DISEASES  OF  THE  STOMACH. 

of  perforating  gastric  ulcer  in  women,  in  thirteen  of  wliicli  there  was 
coexisting  irregularity  or  absence  of  menstruation.  On  the  other 
hand,  "W.  Fox,  *  supported  by  the  observation  of  a  case  of  poisoning 
by  hydrochloric  acid  with  perforating  ulcer,  had  already  expressed  his 
suspicion  that  the  cause  of  the  formation  of  an  ulcer  might  be  "  ex- 
cessive secretion  or  excessive  acidity  of  the  gastric  juice,  especially 
when  the  stomach  was  empty."  But  the  exact  proof  that  the  ulcers 
are  in  many  cases  associated  with  hyperacidity  of  the  gastric  juice  was 
first  brought  forward  by  the  investigations  of  von  den  Yeldeu,  Kie- 
gel,  Ewald,  Jaworsky,  Boas,  and  others.  The  primary  cause  of  the 
ulcer  may  then  be  one  of  the  above-mentioned  accidents.  These 
include  traumatic  or  thermal  irritations,  violent  emesis,  hemorrhages 
due  to  congested  conditions,  hypersemia  and  stasis  in  circumscribed 
vascular  areas  of  the  mucous  membrane,  haemorrhagic  infarctions, 
spasm  of  the  vessels,  and  atheromatous,  amyloid,  or  aneurismal  de- 
generation. But  such  injuries  are,  undoubtedly,  of  frequent  occur- 
rence in  the  stomach  without  being  followed  by  ulcer.  If,  however, 
a  growing  ulcer  develops,  it  is  due  to  the  existence  of  one  or  another 
of  the  anomalies  mentioned.  Repair  begins  only  when  the  latter 
has  been  removed  ;  then  a  reactive  inflammation  of  the  base  of  the 
ulcer  and  of  the  surrounding  tissues  sets  in,  and  its  subsequent  cica- 
trization becomes  possible. 

Here,  too,  lies  the  natural  explanation  of  the  well-knosvn  tend- 
ency of  gastric  ulcers  to  relapse.  According  to  my  conception,  re- 
lapses always  follow  in  those  cases  in  which  the  underlying  affection 
is  transiently  relieved  by  therapeutic  measures,  but  which  returns  to 
the  old  condition  as  soon  as  the  effect  of  the  medication  wears  off. 
This  also  corresponds  with  the  well-known  fact  that  the  greatest 
contingent  of  relapsing  gastric  ulcers  is  drawn  from  those  of  a  nerv- 
ous or  chlorotic  nature,  whose  cure  requires  a  long  time,  and  in 
whom  the  tendency  to  relapse  is  well  marked. 

Perhaps  the  objection  may  be  raised  that  many  diseases  in  which 
there  is  alteration  of  the  composition  of  the  blood  predispose  to  gas- 
tric haemorrhage  without  the  occurrence  of  typical  gastric  ulcers. 

*  W.  Fox.  Chronic  Ulcer  of  the  Stomach.  Reynolds's  System  of  Med.,  vol.  ii, 
p.  930. 


ETIOLOGY  OF  GASTRIC   ULCER.  229 

Thus,  for  instance,  in  cirrhosis  of  the  hver  lisemorrhages  from  the 
gastric  mucous  membrane  due  to  obstruction  in  the  portal  circula- 
tion are  not  uncommon,  yet  the  occurrence  of  gastric  ulcers  is  only 
a  simple  coincidence.  My  answer  is,  that  these  processes  reduce  the 
acidity  of  the  secretion  by  means  of  the  consecutive  hyperseraic  and 
catarrhal  condition  of  the  mucosa.  Consequently,  the  requisite  dis- 
proportion between  the  blood  and  the  gastric  juice  does  not  exist, 
even  though  both  components,  taken  absolutely,  are  found  to  be  al- 
tered. As  predisposing  factors,  however,  we  must  recognize  hyper- 
acidity, of  the  gastric  juice,  as  toell  as  a  change  in  the  composition 
of  the  hlood  in  the  presence  of  the  normal  acidity.  For,  in  spite  of 
the  view  of  Riegel  and  his  pupils,  repeatedly  quoted  in  many  recent 
publications,  that  hyperacid  gastric  juice  is  always  secreted  in  cases 
of  ulcer,  I  must  assert  that,  although  freguent,  this  is  Ijy  no  means 
always  the  case.  Riegel  ^  says  :  "  That  this  hyperacidity  is  a  con- 
stant phenomenon  in  ulcer  can  now  be  regarded  as  positive,  inas- 
much as  the  results  of  382  analyses  in  all  of  the  forty-two  cases 
treated  by  us  during  the  past  year  showed  the  hyperacidity  to  be 
equally  constant."  On  the  other  hand,  Gerhardt  f  formulated  his 
experience  in  a  paper  read  after  the  publication  of  the  first  edition 
of  this  book,  to  the  effect  that  among  twenty-four  patients  with  gas- 
tric ulcer  at  his  clinic  who  were  examined  at  the  proper  time,  in 
seventeen  the  color-tests  showed  hydrochloric  acid,  while  in  seven 
they  did  not.  Still  more  significant  are  the  statements  made  by 
Rosenheim  %  in  the  discussion  following  the  reading  of  Gerhardt's 
paper :  On  examining  the  stomach-contents  with  the  method  of 
Cahn  and  Mering*  in   eight  patients  with  undoubted  ulcer,  only 

*  F.  Riegel.  Beitrage  zur  Diagnostik  der  Magenkrankheiten.  Zeitsehr.  f  ilr 
klin.  Med,  Bd.  12,  S.  434. 

f  C.  Gerhardt.     Ueber  Zeichen  und  Behandhuig  des  einfachen  chronischen  Ma- 
gengeschwurs.    Deutsche  med.  Wochcnschr.,  1888,  No.  18. 
X  Idem.     No.  23. 

*  [The  method  of  Cahn  and  von  Mering  is  based  upon  the  successive  removal  of 
the  organic  acids  from  the  stomach-contents,  the  fatty  acids  being  removed  bv  dis- 
tillation and  the  lactic  acid  by  extracting  with  large  quantities  of  ether :  should  the 
residue  have  an  acid  reaction,  it  can  only  be  due  to  an  inorganic  acid — i.  e.,  HCl. 
The  acidity  is  tested  at  the  different  stages,  and  the  amount  of  the  acids  in  question 
is  thus  calculated.  The  method  is  not  accurate,  for  it  has  not  been  shown  that  the 
residue  is  really  free  HCl.  but  only  that  an  acid  residue  is  obtained,  which  may  be 
either  free  or  combined  HCl  or  both.     The  latter  is  the  accepted  view.     See  Cahn 


230  DISEASES  OF  THE  STOMACH. 

twice  did  lie  find  hyperacidity  (over  0"33  per  cent  of  hydrocliloric 
acid),  in  four  the  acidity  was  within  the  normal  bounds  (0"24-0'33 
per  cent),  and  in  two  there  was  a  diminution  to  0*18  per  cent  in  one 
and  0-16  per  cent  in  the  other.  Even  if,  according  to  von  Pfun- 
gen's  *  investigations,  this  method  by  no  means  shows  only  the  free 
hydrochloric  acid  but  the  total  acidity  which  is  due  to  free  acid  and 
acid  salts  and  which  is  iniiuenced  in  a  variable  and  moreover  un- 
controllable way  by  the  ingesta,  the  fact  nevertheless  remains  that  a 
constant  hyperacidity  does  not  exist  with  ulcer. 

One  case  to  the  contrary  will  suffice  to  overthrow  the  apodictic 
proposition  mentioned  above.  I  have  reported  an  undoubted  case 
of  this  kind  at  the  beginning  of  this  lecture,  and  could  quote  others 
from  my  ease-books.  Disregarding  the  observations  cpoted  above, 
we  may  also  see  exactly  the  same  in  the  estimations  of  acid  in  cases 
of  gastric  ulcer  made  by  Calm  and  von  Mering,  and  by  Eitter  and 
Hirsch.f  The  latter,  in  eight  different  experiments  made  on  five 
patients,  only  twice  found  a  degree  of  acidity  which  was  slightly 
above  normal ;  moreover,  they  established  the  fact  that  hyperacidity 
of  the  stomach-contents,  due  to  hydrochloric  acid,  occurs  in  quite 
healthy  people,  or  at  any  rate  in  those  in  whom  no  stomach  trouble 
is  manifest — an  observation  which  I  also  have  had  many  opportuni- 
ties of  verifying. 

However,  these  cases  are  always  exceptional.  ^Nevertheless, 
they  are  too  important  and  too  firmly  established  to  be  set  aside ; 
consequently  Eiegel's  proposition  should  read,  "In  cases  of  ulcer 
the  gastric  juice  always  contains  hydrochloric  acid,  and  usually  an 
excess  of  it."  I  need  not  enlarge  on  the  importance  of  this  fact  in 
diagnosis,  and  especially  in  differential  diagnosis.  Riegel  maintains 
that,  both  in  consequence  of  this  hyperacidity  and  by  means  of  it, 
an  ulcer  may  develop.     "  On  account  of  the  hyperacidity  an  erosion 

und  von  Mering.  Ueber  die  Sauren  des  gesunden  und  kranken  Magens.  Deutsch. 
Arch.  f.  klin.  Med.,  Bd.  39,  S.  233.  Honigmann  und  von  Noorden.  Ueber  des  Ver- 
halten  der  Salzsaure,  etc.  Zeitschr.  f.  klin.  Med.,  Bd.  13,  S.  87.  Boas,  loc.  cit.,  2. 
Aufl.,  S.  139,— Tr.] 

*  E.  von  Pfungen.  Beitrage  zur  Bestimmung  der  Salzsaure  im  Magensaft. 
Wiener  klin.  Wochenschr.,  1889,  No.  7  u.  ff. 

f  Ritter  und  Hirsch.  Ueber  die  Sauren  des  Magensaftes  und  deren  Beziehung 
zum  Magengeschwiir  bei  Chlorose  und  Anamie.  Zeitschr.  fiir  klin.  Med.,  Bd.  13, 
S.  446. 


ETIOLOGY   OP   GASTRIC   ULCER.  231 

or  injury  of  the  mucous  membrane,  unimportant  in  itself  and  tend- 
ing to  rapid  repair,  attains  a  greater  significance ;  its  liealing  is 
retarded  and  the  ulcer  spreads."  *  A  second  possibility,  and  one 
equally  justified,  is  this,  that  the  hyperacidity,  and  with  it  the  typi- 
cal ulcer,  is  only  developed  in  predisposed  individuals  with  great 
irritability  of  the  nerves  of  secretion,  as  the  result  of  some  damage, 
etc.,  to  the  mucous  membrane.  In  other  words,  as  Hitter  and 
Hirsch  also  say,  the  hyperacidity  may  just  as  well  be  the  result  as 
the  cause  (^or,  as  I  should  say,  the  primary  predisposing  factor)  of 
the  ulcer. 

The  idea  that  the  secretion  of  hyperacid  gastric  juice  is  essential 
for  the  formation  of  a  round  ulcer  is  by  no  means  new,  but,  like  all 
the  questions  with  which  the  pathology  of  the  stomach  has  recently 
been  concerned,  was  expressed  long  ago,  even  if  it  was  not  inyesti- 
gated  by  means  of  exact  methods.  It  is  closely  connected  with  the 
question  of  softening  of  the  stomach — gastromalacia — which,  unless 
it  be  a  post-mortem  phenomenon,  is  nothing  but  a  large  gastric 
ulcer  running  an  acute  course.  Even  Eokitansky  and  Camerer 
believed  that  an  hyperacid  gastric  juice  was  secreted  in  these  cases 
as  the  result  of  a  paralysis  of  the  vagi.  Giinsburgf  directly  pos- 
tulated that  the  existence  of  a  perforating  gastric  ulcer  depended 
upon  the  production  of  an  hyperacid  secretion.  He  says,  "The 
(ulcerative)  destruction  of  the  gastric  mucous  membrane  depends 
upon  a  quantitative  irregularity  in  the  secretion  of  free  acid."  His 
chief  evidence  was  the  fact  that  in  perforating  ulcer  he  found  the 
mucus  of  the  stomach  markedly  acid,  instead  of  its  having  the 
usual  alkaline  reaction ;  he  erred  in  referring  this  hyperacidity  to 
lactic  acid,  in  accordance  with  the  view  then  held  as  to  the  nature 
of  the  acid  of  the  gastric  juice.  However,  it  can  nevertheless  be 
seen  that  here,  as  well  as  everywhere  else,  we  stand  on  the  shoul- 
ders of  our  predecessors,  and  that  the  numerous  public  and  private 
claims  for  priority  made  in  such  profusion,  on  closer  investigation 
shrink  to  very  modest  proportions. 

*  F.  Riegel.  Zur  Lehre  vom  Ulcus  ventriculi  rotundum.  Deutsche  med.  Woch- 
enschr..  1886,  No.  52,  S.  931. 

f  Fr.  Giinsburg.  Zur  Kritik  des  Magengeschwiirs,  insbesondere  des  perforiren- 
den.     Arch.  f.  physiol.  Heilkunde,  xi.  Jahrg.,  1852,  S.  516. 


232  DISEASES  OP  THE  STOMACH. 

Tlie  remarkable  coincidence  of  hums  of  tlie  skin  witli  ulcers  of 
the  stomacli  and  duodenum  in  young  subjects,  first  observed  by 
Curling*  and  later  by  Dupuytren,  Cooper,  Ericlisen,  Wilks,  and 
others,  will  be  no  more  than  mentioned  in  this  place,  inasmuch  as, 
for  the  present,  we  possess  no  knowledge  of  a  possible  interdepend- 
ence of  the  two  processes.  In  125  cases  of  severe  burns  Holmes  f 
found  the  duodenum  ulcerated  in  16,  and  other  jiortions  of  the  intes- 
tine in  two.  The  earliest  period  of  its  appearance  was  from  four 
to  six  days  after  the  burn.  Ulcers  in  the  stomach,  of  which  Roki- 
ansky.  Low,  Wilks,  \  and  Pitt  *  report  cases,  seem  to  be  much 
rarer. 

And,  finally,  micro-orgamsins  have  also  been  brought  forward 
as  the  cause  of  gastric  ulcer.  Letulle  |  found  numerous  streptococci 
in  the  veins  of  the  submucosa  and  of  the  uterus  in  a  case  of  recent 
ulcer  of  the  stomach,  which  appeared  during  the  course  of  puer- 
peral septicaemia.  Pure  cultures  of  these  injected  into  guinea-pigs 
also  caused  ulcerations  in  the  stomachs  of  the  animals,  which  threat- 
ened to  perforate  the  walls  of  the  artificially  distended  organ.  Le- 
tulle obtained  the  same  result  in  four  cases  with  the  staphylococcus 
pyogenes  aureus  cultivated  from  various  abscesses,  and  in  one  case 
with  the  microbes  of  dysentery  discovered  by  Chantemasse  and 
Vidal ;  in  this  case  they  were  derived  from  a  man  who  had  returned 
from  Cochin-China  with  chronic  dysentery,  and  was  attacked  with 
a,  gastric  ulcer.  It  was  claimed  that  the  process  was  either  embo- 
lism or  direct  invasion  of  the  mucous  membrane,  leading  to  necrotic 
spots  and  the  digestion  of  circumscribed  areas.  For  the  present 
the  simple  recording  of  these  statements  will  suffice. 

So  much  concerning  the  presumable  cause  of  ulcers  of  the  stom- 
ach.    I  have  spoken  of  these  views  first  because  at  present  they  are 

*  Curling.  On  Acute  Ulceration  of  the  Duodenum.  Med.-chirurg.  Transact., 
vol.  XXV,  p.  260. 

f  Holmes.     Syst.  of  Surgery,  vol.  i,  p.  733. 

X  Wilks.  Cases  of  Death  from  Burns  and  Scalds.  Case  77,  quoted  by  Falk. 
Ueber  einige  AUgemeinerscheinungen  nach  umfangreichen  Hautverbrennungen. 
Virchow's  Arch.,  1871,  Bd.  53,  S.  27. 

*  Pitt.  Stomach  with  Numerous  Superficial  Erosions  following  after  an  Exten- 
sive Burn.     Transact.  Pathol.  Soc.  London,  1887,  pp.  38,  140. 

II  M.  Letulle.  Origine  infectieuse  de  certains  uleeres  simples  de  I'estomac  ou  du 
duodenum.     Compt.  rend.,  tom.  106,  No.  25. 


OCCURRENCE  OP  GASTRIC  ULCER.  233 

tlie  center  of  interest,  and  because  they  are  naturally  of  great  im- 
portance in  prognosis  and  therapy.  Let  us  now  review  the  clinical 
facts. 

I  shall  first  give  you  a  few  statistics,  which,  as  they  are  compiled 
from  the  records  of  autopsies,  naturally  refer  only  to  the  typical 
perforating  or  cicatrizing  ulcers  : 

Occurrence. — The  frequency  of  ulcer  of  the  stomach  seems  to 
vary  in  different  localities.  Lebert,  it  is  true,  holds  that  on  the 
average  this  is  between  4  and  5  per  cent  [of  the  total  mortality]  for 
Europe,  and  supports  this  statement  by  his  own  statistics  as  well  as 
those  of  Brinton  and  Jaksch  ;  yet  these  averages  are  subject  to  con- 
siderable variations.  Disregarding  the  fact  that  the  figure  estimated 
by  Lebert  for  Jaksch's  statistics  at  5'8  per  cent  is  incorrect,  and 
should  be  3*2  per  cent,  we  find  that  Berthold  gives  2"7  per  cent  for 
Berlin,  and  Nolte  1"23  per  cent  for  Munich,  while,  on  the  other 
hand,  Griess  gives  8*3  per  cent  for  Kiel ;  in  Jena,  it  is  said  to  be  10 
per  cent ;  according  to  Starck,  it  is  13  per  cent  in  Copenhagen.*  In- 
asmuch as  these  results  are  deduced  from  large  numbers,  it  is  to  be 
supposed  that  the  unimportant  errors  have  become  fairly  well  aver- 
aged, and  that  a  certain  regional  difference  is  exliibited.  There  is 
truly  nothing  surprising  in  this,  for  the  causes  of  ulcer  of  the  stom- 
ach are  in  part  referable  to  direct  irritation  of  the  gastric  mucous 
membrane,  and  this  factor  changes  with  the  mode  of  life  and  the 
food-supply  in  the  various  places.  It  has  frequently  been  shown 
that  an  insufficient  diet  may  cause  gastric  ulcer,  as  demonstrated, 
for  instance,  by  Gerhardt's  experiences  in  the  Thuringer  Wald. 
Sohlern,f  proceeding  the  opposite  way,  has  lately  called  attention  to 
the  fact  that  in  certain  districts  of  Germany,  the  Rhon  Mountains 
and  the  Bavarian  Alps,  and  further  in  the  greater  part  of  Russia 
(the  so-called  Grossrussland),  gastric  ulcer  is  a  rarity,  and  that, 
strange  to  say,  the  inhabitants  of  these  regions  exist  almost  exclu- 
sively on  a  vegetable  diet.     Nevertheless,  this  class  of  people,  espe- 

*  [As  Welch  properly  says,  such  statistics  are  based  upon  the  result  of  autopsies 
in  which  all  cicatrices  are  included  as  healed  ulcers.  The  ratio  of  cicatrices  to  open 
ulcers  has  been  placed  at  3  to  1. — Tr.] 

f  Von  Sohlern.  Der  Einfluss  der  Ernahrung  auf  die  Entstehung  des  Magenge- 
schwiirs.     Berl.  klin.  "VVochenschr.,  1889,  No.  14. 


234  DISEASES  OF  THE  STOMACH. 

cially  in  Russia  and  Bavaria,  is  in  general  well  nonrished  and  pow- 
erful. ISTow,  as  it  is  well  known  that  much  more  potassium  is  added 
to  the  blood  on  a  vegetable  diet,  nearly  a  third  more  than  on  a  mixed 
diet,  so  this  permanently  increased  addition  necessarily  brings  with 
it  an  increase  in  the  amount  of  this  metal  in  the  blood ;  while,  ac- 
cording to  other  investigations,  the  red  blood-cells  are  to  be  re- 
garded as  the  chief  carriers  of  potassium.  Sohlern  claims  that  this 
increased  amount  would  represent  the  cause  of  the  relative  immu- 
nity of  the  above-mentioned  classes  from  ulcer  of  the  stomach,  quite 
in  accordance  with  the  rare  occurrence  of  this  disease  in  vegetarians, 
whose  blood,  as  is  well  known,  is  rich  in  potassium  phosphate.  On 
the  other  hand,  diseases  accompanied  by  an  impoverishment  or 
change  in  the  red  blood-cells,  such  as  chlorosis,  ansemia,  etc.,  might 
tend  to  the  development  of  ulcer  because  they  produce  blood  which 
is  poor  in  potassium. 

For  the  present,  as  Sohlern  himself  says,  these  very  interesting 
considerations  lack  the  support  of  a  series  of  examinations  of  blood 
made  for  the  purpose  ;  but  even  without  these  the  significance  of 
the  facts  advanced  can  not  be  denied. 

Statistics  show  great  unanimity  regarding  the  remainder  of  the 
accessible  factors — sex,  age,  site  of  the  ulce7\  2in^  frequency  of  per- 
foration. It  is  universally  found  that  females  are  more  frequently 
affected  than  males,  the  average  proportion  being  as  two  to  one. 
Further,  on  consideration  of  all  the  factors  involved,  it  is  without 
doubt  that  it  most  commonly  occurs  between  the  ages  of  twenty  and 
forty,  while  the  greatest  mortality  is  found  between  forty  and  sixty 
years.  These  facts  are  in  no  way  altered  by  Griinfeldt  -  having 
found  scars  of  gastric  ulcers  92  times  (20  per  cent)  in  450  autopsies 
on  old  people,  or  by  Chiari's  f  case  of  a  recent  perforation  in  a  man 
seventy-one  years  old,  or  Sedgwick's:);  similar  case  in  which  the 
man  was  eighty-two  years  old,  nor  by  the  fact  that,  according  to 
Henoch,*  ulcers  of  the  stomach  are  fairly  frequent  in  children,  and 

*  Griinfeldt.     Hospitaltid,  2.  R.  ix,  p.  765,  quoted  in  Virchow-Hirsch's  Jahrb., 
1878. 

\  Chiari.      Fall   von   Perforation   eines   Magengeschwilrs.   Anzeiger  der  k.  k. 
Gesellsch.  d.  Aerzte  zu  Wien,  1880,  S.  161. 

X  Sedgwick.     On  Perforating  Ulcer  of  the  Stomach.     Dublin  Hosp.  Gaz.,  1855. 

*  Henoch.     Vorlesungen  iiber  Kinderkrankheiten.     Berl.,  1883,  2.  Aufl.,  S.  61. 


PATHOLOGY  OF   GASTRIC   ULCER.  235 

even  in  the  new-born.  The  latter,  at  all  events,  have  nothing  in 
common  with  typical  gastric  ulcer,  inasmuch  as  they  are  probably 
caused  by  intra-uterine  poisons,  or  by  those  connected  with  parturi- 
tion, and  since  they  do  not  last  beyond  earliest  infancy.  At  any 
rate,  on  reference  to  the  mortality  tables,  we  find  that  childhood, 
till  the  tenth  or  fifteenth  year,  is  practically  entirely  exempt.  On 
the  other  hand,  I  think  it  very  probable  that  ulcers  of  the  stomach 
occur  at  this  age,  but  that,  owing  to  the  more  active  regenerative 
and  plastic  powers  of  the  tissues  in  childhood,  the  tendency  to  re- 
covery is  greater  than  at  a  more  advanced  age.  I  have  observed  at 
least  two  cases  which  I  could  only  regard  as  gastric  ulcer,  and  in 
which  nothing  but  haemorrhage  was  needed  to  complete  the  typical 
picture.  Unquestionably,  however,  they  are  of  much  rarer  occur- 
rence than  in  later  years,  because  the  injurious  factors  are  by  far 
less  common  in  childhood. 

Whether  occupation  plays  any  role  in  the  causation  of  round 
ulcer,  as  is  frequently  accepted,  appears  more  than  doubtful  to  me, 
accordino:  to  what  I  have  said  at  the  beo-innino;  of  this  lecture. 
IN^evertheless,  I  will  again  mention  the  well-known  fact  of  its  fre- 
quent occurrence  in  female  servants,  and  especially  in  cooks.  In 
English  literature  insufficient  food  is  more  often  given  among  the 
causes,  and  we  also  find  a  parallel  drawn  between  it  and  the  oc- 
currence of  ulcers  of  the  cornea  in  cachectic  and  much  enfeebled 
patients. 

Pathological  Anatomy. — A  large  number  of  the  ulcers  undoubt- 
edly arises  from  direct  lesions  to  the  vessels  and  their  result,  hsemor- 
rhagic  infarction,  whether  it  be  that  the  primary  cause  lies  in  the 
obstruction  of  the  smallest  arterial  twigs  which  run  up  between  the 
glands  of  the  mucous  membrane  from  the  submucosa,  or  whether 
it  be  that  atheromatous,  amyloid,  or  aneurismal  degeneration 
of  the  vascular  walls,  cerebral  injuries,  or  even  the  simple  pro- 
cesses of  the  stoppage  of  the  circulation,  predispose  to  the  rupture 
of  the  vessels.  These  processes — i.  e.,  the  formation  of  hsemor- 
rhagic  infarctions — are  excellently  described  by  Hauser,*  with  whom 
I  can  almost   entirely  agree,  as  the  result  of  experiments  made  by 

*  G.  Hauser.     Das  chronische  Magengeschwiir.     Leipzig.  1883. 


238  DISEASES  OF  THE  STOMACH. 

me,  in  part  with  Dr.  George  Meyer,  wliich  I  shall  fully  describe 
elsewhere. 

But  these  causes  are  not  alone  sufficient,  because  numerous  cases 
occur,  especially  in  youthful  individuals,  in  which  no  indication 
either  of  disease  of  the  vessels  or  of  the  other  enumerated  factors 
exists.  Here  we  must  assume  that  the  ulcers  are  developed  from 
the  follicular  hsemorrhages  and  the  hsemorrhagic  erosions  of  Roki- 
tansky,  which  in  a  small  way  represent  the  same  thing  that  h  hemor- 
rhagic infarctions  do  on  a  large  scale,  namely,  the  withdrawal  of 
the  normal  nourishment  from  small  areas  of  the  mucous  membrane. 
Carswell,  in  his  atlas,*  pictures  an  exquisite  example  of  follicular 
hsemorrhages  with  punctate  htemorrhages  in  the  mouths  of  the 
crypts  partly  surrounded  by  a  round  zone  of  extravasated  blood. 
In  a  stomach,  the  mucous  membrane  of  which  was  suffused  with 
blood,  and  which  I  treated  very  soon  after  death  according  to  Heid- 
enhain's  method  (placing  small  pieces  of  tissue  immediately  in  abso- 
lute alcohol  which  must  be  frequently  changed,  and  staining  with 
hsematoxylin  and  bichromate  of  potassium),  I  found  the  ducts  of  the 
glands  packed  full  of  red  blood-cells  to  beyond  the  neck — i.  e., 
down  into  the  fundal  portions.  These  could  only  have  had  their 
origin  in  a  haemorrhage  on  the  surface  of  the  mucous  membrane, 
which  in  its  turn  could  only  have  come  from  the  fine  capillary  net- 
work (Henle)  situated  close  beneath  the  free  surface  of  the  nmcous 
membrane.  Such  haemorrhages  may  be  due  to  a  very  unimportant 
stoppage  of  the  circulation,  or  to  a  traumatism,  etc.  They  develop 
into  heemorrhagic  erosions,  small  streak-like  or  rounded  losses  of 
substance  from  the  size  of  a  millet-seed  to  that  of  a  pea,  on  which 
at  times  a  blackish-brown  extravasation  of  blood  is  found,  together 
with  the  simultaneous  loosening  of  the  mucous  membrane.  Their 
number  is  very  variable,  being  sometimes  enormous,  especially  near 
the  pylorus,  so  that  the  stomach  appears  as  if  sown  with  them. 
From  the  erosion  the  typical  chronic  ulcer  is  developed.  Accord- 
ing to  Forster's  f  conception,  this  is  the  usual  course  of  formation  of 
the  ulcus  rotundum,  while  we  now  know  that  this  takes  place  only 


*  [Carswell.     Loc.  cit.'\ 

f  FOrster.     Lehrbuch  der  speciellen  pathol.  Anatomie.     Leipzig,  1854. 


PATHOLOGY   OF   GASTRIC   ULCER.  237 

in  a  limited  number  of  cases  in  wliicli  lisemorrliagic  infarction  can 
not  be  made  to  explain  its  appearance. 

But  whether  the  causation  of  the  ulcer  be  due  to  one  or  the 
other,  it  can  nevertheless  never  be  regarded  as  an  "  ulcer,"  viewing 
it  from  the  standpoint  of  pathological  anatomy ;  it  is  rather  a 
"  progressive  necrosis  of  tissue,"  in  which  the  characteristic  feature 
of  an  ulcer,  "  the  proliferation  of  young  cellular  elements  which 
always  spreads  deeper  into  the  tissues,  and  continually  throws  more 
elements  to  the  surface,"  *  is  entirely  lacking.  The  ulcer  does  not 
grow  by  an  active  process  in  the  tissues  with  subsequent  necrosis, 
but  by  a  passive  one.  The  participation  becomes  active  only  on 
the  ap]3earauce  of  the  cellular  infiltration  which  leads  to  cicatri- 
zation. 

In  microsco]3ic  sections  through  the  margin  of  a  recent  ulcer  the 
ducts  of  the  glands  are  seen  to  descend  trough-hke  [muldenfdrmig\ 
and  as  though  cut  off  toward  the  base  of  the  ulcer.  They  are  sim- 
ply eaten  away  or  digested  as  far  as  the  tissues  could  offer  no  re- 
sistance to  the  digestive  power  of  the  gastric  juice.  It  is  only  in 
older  ulcers  that  a  reactive  inflammation  sets  in  at  the  periphery, 
leading  to  the  formation  of  a  callous  margin.  Here  the  trabeculse 
between  the  remaining  ducts  are  thickened  and  in  part  placed  ob- 
liquely, a  condition  which  would  appear  to  be  analogous  to  a  dis- 
covery of  "Witosowski's,  which  will  be  mentioned  directly  [page 
238].  As  much  of  the  glandular  epithelium  as  is  present  in  the 
fundal  portions  of  the  remaining  ducts  has  undergone  a  remarkable 
change.  In  the  place  of  the  peptic  cells  we  find  cuboidal  or  cylin- 
drical epithelium ;  they  are  shrunken  so  that  they  are  separated  both 
from  the  membrana  propria  and  from  one  another  ;  their  nuclei  can 
not  be  recognized  by  staining,  and  their  contents  are  of  a  broken- 
down,  light,  glassy  appearance,  which  reminds  one  most  of  hyaline 
degeneration.  Single  ducts  have  undergone  cystic  degeneration. 
The  submucosa  is  decidedly  broader  and  thicker,  with  an  abundant 
infiltration  of  small  cells,  and  with  a  rich  vascular  network ;  the 
bands  of  muscular  fibers  of  the  muscularis  in  some  portions  are  sepa- 
rated by  connective  tissue  which  is  partly  fibrillar,  partly  torn  apart  in 

*  Virchow.     Cellularpathologie,  4  Aufl.,  S.  537. 


238  DISEASES  OF  THE  STOMACH. 

meshes,  and  in  other  portions  they  have  been  entirely  replaced  by 
it.  We  see,  therefore,  that  the  necrotic  process  is  surrounded 
in  its  entire  extent,  both  at  the  margin  and  the  base,  by  a  zone 
which  is  the  seat  of  irritative  processes,  which  subsequently  lead 
on  to  true  cicatrization.  This  always  causes  the  firm  attachment 
of  the  base  of  the  ulcer  to  the  underlying  tissue,  and  the  inversion 
of  the  mucous  membrane  at  the  edge  into  the  substance  of  the 
ulcer. 

Witosowski  *  claims  that  the  ducts  of  the  glands  situated  at  the 
margin  of  the  ulcer  become  bent  so  that  their  mouths  are  turned  to- 
ward the  ulcer,  and  thus  pour  their  secretion  directly  into  it.  He 
holds  that  a  corroding  ulcer,  which  always  develops  at  the  bottom  of 
the  furrows  produced  by  the  folds  of  mucous  membrane,  can  only  be 
formed  by  these  means  or  by  a  simultaneous  process  of  proliferation 
proceeding  from  the  submucosa.  The  former  is  for  the  most  part 
true,  and  can  be  explained  by  the  impeded  circulation  of  the  parts. 
I  have  never  seen  the  latter,  and  I  can  not  regard  the  singular  the- 
ory which  Witosowski  has  founded  upon  it  as  being  open  to  discus- 
sion. At  all  events,  in  old  ulcers  the  ducts  of  the  glands  are  direct- 
ed toward  the  crater  of  the  ulcer,  as  has  already  been  stated  by 
Hauser,  and  as  I  can  fully  corroborate,  but  it  is  only  because  the 
elasticity  of  the  muscular  coat  causes  it  to  retract  and  draw  away 
under  the  mucosa  ;  however,  from  the  very  nature  of  things,  a  secre- 
tion from  these  ducts  is  no  longer  possible.  In  the  interstices  we 
always  find  a  profuse  small-celled  infiltration,  but  there  is  nothing 
specially  characteristic  of  ulcer  in  this,  as  it  is  found  in  all  processes 
leading  to  inflammatory  irritation  of  the  macous  membrane,  from  a 
mild  catarrh  to  an  acute  phlegmonous  gastritis.  A  common  result 
of  the  ulcer,  however,  is  an  accompanying  irritable  condition  of  the 
surrounding  portions  of  the  mucous  membrane.  And,  finally,  it  is 
to  be  noted  that  a  number  of  originally  separate  ulcers  may  coalesce 
to  form  one  large  one. 

The  views  just  unfolded  are  of  the  highest  importance  in  the 
practical  treatment,  because  it  must  necessarily  follow  that  ulcer  of 


*  Witosowski.     Ueber  das  Verhaltniss  der  productiv  entziindlichen  Processe  zu 
den  Ulcerosen  im  Magen.    Virchow's  Arch.,  Bd.  94,  S.  543. 


PATHOLOaY  OP  GASTRIC   ULCER.  239 

the  stomach  can  be  attacked  from  two  sides,  directly  and  indirectly, 
by  means  of  local  and  of  general  treatment. 

The  gross  anatomy  of  gastric  ulcer  and  its  consequences  I  can 
dispose  of  in  a  few  words.  Its  form,  like  a  funnel  or  crater,  is  well 
known ;  the  margin  is  at  first  sharply  defined,  and  only  becomes 
thickened  and  wall-like  later  on.  There  is  not  a  medical  student 
who  does  not  know  Rokitansky's  classical  comparison  that  an  ulcer 
looks  "  as  though  cut  out  with  a  punch,"  although  this  can  only  be 
applied  to  old  perforating  ulcers ;  while  among  the  othei'S  are  found 
linear,  oval,  insular,  or  step-like  forms.  For  the  most  part  the  base 
of  the  ulcer  is  smooth,  or  with  only  a  few  inequalities,  but  occasion- 
ally it  is  covered  with  small  blood-clots  or  with  tenacious  greenish 
or  brownish  mucus. 

The  size  varies  considerably,  being  usually  that  of  a  10-pfennig 
piece  [5-cent  nickel]  to  a  mark  [silver  quarter-dollar].  Generally 
the  ulcer  observed  by  Cruveilhier,  16  centimetres  [6|-  inches]  in 
length,  and  8*5  centimetres  [3f  inches]  in  width,  is  referred  to  as  a 
prodigy ;  but  I  have  found  a  case  described  by  Habershon  in  which 
the  process  involved  nearly  the  entire  surface  from  the  pylorus  to 
the  cardia. 

The  site  is  preferably  at  the  pylorus  and  the  greater  curvature, 
corresponding  to  the  most  dependent  portion  of  the  stomach  where 
the  gastric  juice  collects  in  the  erect  posture ;  hence  l*^olte  gives  the 
■  following  scale  of  frequency :  At  the  greater  curvature  22,  at  the 
pylorus  13,  anterior  wall  3,  posterior  wall  2,  cardia  1.* 

In  the  majority  of  cases  only  one  ulcer  is  present ;  more,  up  to 
three  or  over,  are  rare.  However,  Lange  saw  so  many  of  them  in 
one  case,  that  "  he  had  to  give  up  the  attempt  to  count  them  all."  f 


*  [Welch,  as  the  result  of  the  analysis  of  793  cases,  gives  the  following : 

Lesser  curvature 288  (36'3  per  cent) 

Posterior  wall 235(29-6        "       ) 

Pylorus 95  (12-  "       ) 

Anterior  wall 69  (  87        "       ) 

Cardia 50(6-3         "       )     • 

Fundus 29(3-7        "       ) 

Greater  curvature 27  (  3-4        "       ) 

Pepper's  System  of  Medicine,  vol.  ii,  p.  503. — Tr.] 

t  Lange.    Deutsche  Klinik,  1860,  S.  90.     "  In  addition  to  this  (i.  e.,  the  perfo- 
rating ulcer)  there  was  not  only  an  immense  number  of  scars  of  various  sizes  and 


240  DISEASES  OF  THE  STOMACH. 

Finally,  if  in  the  course  of  the  process  the  base  of  the  ulcer  be- 
comes thickened  and  like  a  plate,  and  the  margins  indurated  and 
wall-like,  and  if  its  site  be  such  that  the  spot  is  appreciable  on  pal- 
pation, it  can,  on  this  account,  convey  the  impression  of  an  ulcer- 
ating malignant  neoplasm,  as  I  shall  discuss  more  particularly  later 
on.  If,  however,  the  ulcer  is  situated  either  in  the  region  of  the 
pylorus  or  of  the  cardia,  the  cicatrization  may  cause  stenosis  of  these 
openings  with  its  clinical  sequelae. 

The  results  of  the  necrotic  process  are  of  special  interest.  We 
must  distinguish  between — 

1.  Cicatrization.  Here  there  exists  a  marked  distinction  from 
the  ulcers  artificially  produced  in  animals ;  for,  while  these  heal  with 
restitution  of  the  normal  mucous  membrane,  as  Cohnheim  states, 
and  as  I,  too,  have  found,  in  man  a  fibrous,  centrally  depressed 
scar  is  formed,  with  the  well-known  tendency  to  contraction.  This 
leads  to  radiating  scars  and  to  distortion  of  the  gastric  wall,  espe- 
cially if  a  fixed  point  has  been  established  by  previous  adhesions  to 
the  neighboring  organs.  Girdle-like  constrictions  of  the  viscus  oc- 
cur, giving  it  the  form  of  an  hour-glass  or  a  gourd.  In  this  way,  if 
the  scar  is  situated  in  the  lesser  curvature,  the  pylorus  and  cardia 
may  be  drawn  together  to  such  a  degree  that  a  lead-pencil  can 
scarcely  be  passed  between  them,  as  is  seen  in  the  specimen  (dried 
in  superheated  air)  which  I  here  show  you.  Thus,  also,  very  pe- 
culiar cicatricial  bands  or  bridges  may  be  formed,  which  lead  to  the 
formation  of  a  complete  sac,  of  which  Cruveilhier  *  gives  an  excel- 
lent drawing  in  his  large  work. 

2.  Progressive  necrosis  and  corrosion.  If  cicatrization  does 
not  occur,  the  necrotic  process  continues  as  long  as  any  gastric  juice 
is  secreted,  finally  causing  its  own  cessation  by  means  of  the  ensuing 
complications.     These  are : 

(a)  Corrosion  of  the  vessels.  Vessels  of  larger  or  smaller  caliber 
are  opened  according  to  the  site  of  the  ulcer  and  to  its  extension 


depths  all  over  the  walls  of  the  stomach,  but  also  such  a  quantity  of  uncicatrized 
ulcers,  some  extending  only  into  the  mucosa,  others  penetrating  even  into  the  raus- 
cularis,  some  flat,  some  in  the  shape  of  holes,  and  others  funnel-like,  that  I  had  to 
give  up  the  attempt  to  count  them  all." 
*  Loc.  cit.,  20.  Livrais,  PL  6. 


TUBERCULAR  ULCERS.  241 

into  the  tissues.  The  slight  tendency  to  thrombosis  is  a  character- 
istic feature,  which  is  probably  connected  with  the  digestive  action 
of  the  gastric  secretion.  Among  the  larger  vessels  most  frequently 
affected  are  the  gastric,  splenic,  and  pancreatic  arteries. 

(5)  Adhesions  to  neighboring  organs  and  perforation.  If  the 
necrosis  extends  to  the  serosa,  it  leads  either  to  a  reactive  inflamma- 
tion and  adhesion  to  surrounding  organs,  and  consequent  spread  of 
the  process  to  them ;  or,  where  circumstances  will  not  permit  this, 
to  a  direct  perforation  into  the  abdominal  cavity.  There  may  also 
be  secondary  perforations  into  the  pleural  or  pericardial  cavities 
through  the  corresponding  interposed  tissues.  According  to  the 
site  of  the  ulcer,  all  the  neighboring  organs,  liver,  gall-bladder,* 
pancreas,  spleen,  diaphragm,  heart,  lungs,  and  intestines  are  subject 
to  this  possibility.  At  times  it  may  produce  adhesions  among  or- 
gans situated  near  one  another  in  the  abdominal  cavity — such  a  case 
being  described  by  Budd. 

Finally,  tiibercular  and  syphilitic  ulcers  must  be  mentioned. 

Tubercular  Ulcers. — Thus  far  these  have  only  been  found  in  con- 
nection with  tubercular  lesions  in  other  organs.  They  are  charac- 
terized by  their  thickened,  infiltrated,  wall-like  margins ;  the  base  is 
for  the  most  part  yellowish  and  granular.  They  are  pale,  and,  as 
seen  in  Eppinger's  f  cases,  they  thus  present  a  sharp  contrast  to 
their  dark-colored  surroundings.  In  the  margins  and  base  tubercu- 
lar nodules  with  their  characteristic  giant-cells  are  found.  There 
may  be  one  or  more  ulcers,  involving  only  the  mucosa  and  sub- 
mucosa,  or  extending  down  to  the  muscularis.  In  a  few  cases  (Lit- 
ten  X)  the  serous  coat  over  the  base  of  the  ulcer  is  strewn  with  mili- 
ary tubercles.  In  Litten's  case  the  ulcer  was  fairly  large — 4'2x3'3 
centimetres  [l"Yxl'3  inch).  The  edges  were  sharp  and  indurated, 
and  in  parts  swollen  and  infiltrated  with  blood.  The  rest  of  the 
digestive  tract  was  free  from  tubercular  ulcerations,  but  they  were 
found  in  the  larynx,  bronchi,  and  lungs.     A  similar  case  is  reported 

*  Habershon.     Lancet,  June  2,  1883,  p.  951. 

f  Eppinger.     Ueber  Tuberculose  des  Magens  und  (Esophagus.      Prager  med. 
Wochenschr.,  1881,  No.  51  u.  52. 

\  M.  Litten.     Ulcus  yentriouli  tubereulosum.     Virchow's  Archiv,  Bd.  67,  S.  615. 


242  DISEASES  OF  THE  STOMACH. 

by  Talamon-Balzer,*  another  by  Gilles-Sabourin,f  and  Eppinger :}: 
lias  described  two  others.  [An  excellent  description  of  tubercular 
ulcer  of  the  stomach  will  be  found  in  a  paper  by  Musser,  *  in  which 
he  describes  a  case,  a  negro  forty-four  years  of  age,  with  pul- 
mony  phthisis  and  vague  gastric  symptoms ;  on  autopsy,  an  ulcer, 
li  X  3|-  inches,  was  found  in  the  stomach ;  the  ulcer  was  evidently 
tubercular,  and  contained  cheesy  matter,  as  well  as  miliary  tubercles 
in  the  base  and  in  the  submucosa  in  the  vicinity.  Tubercle  bacilli 
were  found  in  the  cheesy  masses  y  they  were  also  found  in  some 
other  cases  which  he  mentions  in  his  quite  complete  bibliography. 
Most  of  the  cases  have  been  observed  in  children. — Te.]  However, 
all  these  do  not  belong  to  the  type  of  the  corresponding  ulcer ;  they 
are  rather  true  areas  of  tubercular  softening  as  they  occur  every- 
where with  central  cheesy  degeneration  of  the  tubercle  tissue.  At 
all  events,  there  is  a  combination  with  the  corrosive  action  of  the 
gastric  juice  on  the  necrotic  tissue  elements. 

The  syphilitic  ulcer  is  not  marked  by  characteristic  anatomical 
features.  In  the  majority  of  the  few  cases  thoroughly  observed,  the 
question  whether  the  ulcer  was  a  primary  lesion  or  a  broken-down 
gumma  is  not  broached.  || 

Symptoms. — As  is  well  known,  some  gastric  ulcers,  healing  by 
cicatrization,  run  their  course  during  life  without  presenting  any 
symptoms  whatever,  or  only  a  few  which  are  not  at  all  character- 
istic ;  they  are  then  only  found  accidentally  after  death.  Their 
occurrence  had  already  been  established  by  Williams,  Abercrombie, 
and  Chambers,  and  naturally  they  do  not  come  under  clinical  obser- 
vation. 

The  various  ulcers  of  the  stomach  may  be  arranged,  according  to 
their  symptoms,  into  the  following  groups  : 

1.  Cases  in  which  the  symptoms  due  to  irritation  predominate, 


*  Talamon-Balzer.  Phthisie  locale ;  ulcerations  tuberculeuses  de  I'estomac  et 
de  I'intestin.     Bull.  Soc.  anatom.,  1878,  p.  374. 

f  Ibid.  X  ^0'^-  ^'^i- 

*  [J.  H.  Musser.  Tubercular  Ulcer  of  the  Stomach.  Philadelphia  Hospital  Re- 
ports, 1890,  vol.  i,  pp.  117-124. — Also,  Barlow.  Transactions  of  Patholog.  Society 
of  London,  1887,  vol.  xxxviii. — Tr.] 

II  Galliard.  Syphilis  gastrique  et  ulcere  simple  de  I'estomac.  Arch,  gener.de 
med.,  1886,  pp.  66  et  seq. 


SYMPTOMS  OF   GASTRIC  ULCER.  243 

and  which  result  in  hasmorrhagic  erosions,  or  in  corrosion  and  ex- 
posure of  a  larger  or  smaller  portion  of  the  mucous  membrane  with- 
out the  development  of  further  complications. 

2.  Cases  with  these  symptoms  of  irritation,  together  with  haem- 
orrhages. 

3.  Cases  with  symptoms  of  irritation  and  perforation,  resulting 
in  recovery  or  death. 

4.  Cases  which  remain  latent  until  death  occurs  by  haemorrhage 
or  perforation. 

The  fact  that  the  symptoms  of  the  first  three  groups  may  be 
combined  in  various  ways  explains  why  the  clinical  picture  is  so 
changeable ;  and  if,  in  addition,  the  results  of  cicatrization  are  also 
included,  it  becomes  even  more  complicated.  The  first  stages  mani- 
fest themselves  by  those  conditions  of  discomfort  which  we  find  at 
the  commencement  of  so  many  diseases  of  the  stomach,  such  as 
vague  sensations  of  pressure,  transient  drawing  pains,  and  the  ac- 
companyin.g  disturbances  of  the  appetite.  However,  the  tongue  is 
usually  clean,  or  only  moderately  coated  at  the  base.  On  strict  in- 
quiry we  find  that  the  patients  eat  very  little,  and  usually  keep  a 
fairly  strict  diet,  not  on  account  of  lack  of  apjDctite,  but  owing  to 
the  dread  of  having  pain  after  a  full  meal.  For  this  gastralgia 
forms  a  marked  feature  of  the  picture,  even  early  in  the  disease. 
The  accompanying  catarrhal  gastritis  is  but  rarely  sufiiciently  marked 
to  cause  true  anorexia,  foul  taste,  belching,  bad  odor  from  the 
mouth,  and  heavily  coated  tongue. 

Only  in  the  rare  cases  in  which  a  girdle-like  ulcer  or  a  cicatrix 
interferes  with  the  peristalsis  of  the  stomach  and  causes  dilatation, 
is  there  marked  decomposition  of  the  stomach-contents  and  belch- 
ing of  foul  gases.  Sluggishness  of  the  bowels  is  the  rule ;  diarrhoea, 
or  a  condition  in  which  the  two  alternate,  the  exception.  The 
intestinal  functions  are  rarely  found  to  be  normal  and  undis- 
turbed. 

Chronic  ulcer  runs  its  course  without  fever,  and,  should  an  in- 
creased temperature  be  present  in  conditions  of  exhaustion  toward 
the  end  of  life,  or  in  certain  forms  of  ulcer  running  an  acute  course, 
they  are  due  to  inflammatory  processes,  such  as  gastritis,  perito- 
nitis, or  pneumonic  infiltrations. 
16 


2i4  DISEASES  OP  THE  STOMACH. 

Recent  cases  are  not  usually  accompanied  by  disturbances  of 
nutrition ;  they  may  even  be  absent  after  the  ulcer  has  existed  for 
some  time.  Most  patients,  however,  eventually  emaciate  on  account 
of  their  scanty  diet,  and  frequently  lose  weight  so  rapidly  as  to 
cause  apprehension,  so  that  losses  of  20  kilogrammes  [44  pounds] 
and  more  in  a  few  months  are  not  uncommon.  This  depends  partly 
on  the  previous  condition,  and  occurs  more  frequently  in  the  strong 
and  stout  than  it  does  in  lean  persons. 

Gradually  the  pains  become  localized  to  a  definite  spot  corre- 
sponding to  the  site  of  the  ulcer,  and  as  this  is  commonly  situated 
in  the  lower  half  of  the  stomach,  and  as  the  painful  spot  can  not  be 
localized  with  exactness,  it  is  usual  to  have  it  referred  to  the  infra- 
sternal  depression.  The  boring,  sharply  localized  pain,  frequently 
darting  from  before  backward,  is  characteristic.  Some  patients 
complain  only  of  pain  in  the  back,  others  of  "  stitches  in  the  side," 
owing  to  which  the  disease  may  be  mistaken  for  intercostal  neu- 
ralgia. As  a  rule,  pressure  increases  it  ;  women  can  not  lace,  and 
men  can  not  pull  the  band  of  their  trousers  tight.  In  rare  cases,  on 
the  other  hand,  pressure  eases  the  pain.  It  appears  in  attacks  most 
frequently  on  mechanical  or  thermal  irritation  of  the  exposed  sur- 
face of  the  ulcer.  Of  course,  this  is  primarily  and  most  frequently 
the  case  after  eating,  the  food  either  causing  direct  irritation  on  its 
introduction,  or  stretching  the  wall  of  the  stomach  by  its  weight,  or 
the  surface  of  the  ulcer  is  distorted  and  its  nerves  irritated  by  the 
contractions  accompanying  digestion.  But  this  is  not  the  only 
cause.  I  have  repeatedly  seen  severe  gastralgia  in  patients  with 
ulcer  of  the  stomach,  after  a  drink  which  was  too  cold,  or  a  spoon- 
ful of  soup  or  tea,  etc.,  which  was  too  hot ;  in  these  cases,  conse- 
quently, the  pain  could  not  be  attributed  to  the  above-mentioned 
factors,  but  only  to  thermal  irritation.  Moreover,  according  to  my 
experience,  ingesta  which  are  too  hot  are  less  often  the  cause  than 
those  which  are  too  cold,  perhaps  because  the  mouth  and  throat  act 
as  guards  to  the  stomach  in  the  former  case,  and  because  the  mu- 
cous membrane  of  the  stomach  is  more  tolerant  of  high  degrees  of 
temperature  than  it  is  of  low,  and  also  because  smaller  quantities  of 
the  former  are  taken  than  of  the  latter.  The  state  of  the  ingesta  is 
also  certainly  not  without  influence  on  the  reaction  of  the  mucous 


SYMPTOMS   OP  GASTRIC   ULCER.  245 

membrane.     A   remarkable  example  of  this  is  recorded  bj  Dim- 
glison  :  * 

Numerous  cases  of  severe  acute  gastritis  occurred  among  the  workmen 
in  Virginia  who,  becoming  overheated  under  the  hot  sun,  quenched  their 
thirst  with  large  quantities  of  cold  spring-water  ;  these  attacks  were  rap- 
idly followed  by  death.  On  substituting  small  pieces  of  ice  instead  of  the 
water,  this  disease  practically  disappeared. 

To  be  sure,  there  are  many  patients  who  never  have  trouble 
after  eating,  but  instead  the  attacks  of  gastralgia  appear  when  the 
stomach  is  empty,  and  even  in  the  night.  Here  the  cause  may  be 
the  secretion  of  hyperacid  gastric  juice,  which  is  still  to  be  spoken 
of.  On  the  other  hand,  gastralgia  may  be  caused  by  the  distention 
of  the  walls  of  the  stomach  by  gases,  or  by  irritation  of  the  nerve- 
fibers  due  to  the  progressing  process  of  ulceration,  while  the  attacks 
of  gastralgia  caused  by  colds  and  excitement,  and  the  increased 
pain  before  the  menstrual  ej)och  and  its  cessation  on  the  appearance 
of  the  menses,  may  be  regarded  as  reflex  in  character,  A  peculiar 
symptom  occasionally  seen  is  the  cutaneous  hypersesthesia  and 
ansestliesia  observed  by  Traube  f  and  referred  by  him  to  a  central 
"  irradiation."  The  causes  of  the  gastralgias  lead  to  the  fact  that 
they  usually  appear  suddenly  and  with  great  intensity  at  once,  and 
as  rapidly  subside,  so  that  a  nearly  normal  condition  is  very  soon 
established  ;  paroxysms  w^hich  gradually  increase  in  intensity  are 
less  frequently  observed. 

Vomiting  usually  occurs  soon  after  eating.  It  is  due  to  the  irri- 
tation caused  by  the  food,  and  not  to  an  accumulation  of  ingesta,  as 
is  the  case  in  dilatation  of  the  stomach.  The  food  is  brought  up 
only  slightly  changed  and  mixed  with  some  mucus,  as  in  the  morn- 
ing vomiting  of  drunkards.  Fermentation-fungi  and  other  foreign 
cellular  elements,  with  the  exception  of  the  occasional  admixture  of 
blood,  are  absent,  or  (for  example,  sarcinse)  are  very  rare. 

JI(Em,02}tysis. — When  the  blood  comes  from  small  vessels,  the 
quantity  is  usually  small ;  if  recent,  it  appears  only  as  fine  bloody 
streaks  in  the  vomit ;  but  if  the  gastric  juice  has  had  an  opportunity 
to  act  for  a  longer  time  upon  the  blood  while  it  was  accumulating, 

*  Quoted  by  Copeland.  Dictionary  of  Praet.  Med.,  article  Indigestion. 
f  Traube.    Deutsche  Klinik,  1861,  S.  63. 


24:6  DISEASES  OP  THE  STOMACH. 

then  it  is  changed  to  reddish-brown,  granular  masses.  Small  quan- 
tities of  blood  may  easily  escape  observation  when  no  vomiting  oc- 
curs and  the  blood  is  carried  into  the  intestines ;  here  it  is  altered 
to  such  an  extent  that  nothing  is  noticeable  by  simple  inspection  of 
the  fgeces.  Under  such  circumstances  the  blood  in  the  stool  can 
only  be  demonstrated  by  a  microscopic,  spectroscopic,  or  chemical 
examination.  In  this  way  the  cause  of  an  obscure  anaemia  may  be 
discovered.  In  fact,  this  is  possible  much  more  frequently  than  is 
generally  assumed ;  consequently,  repeated  examination  of  the  faeces 
should  not  be  omitted  after  gastralgic  attacks,  or  indeed  in  any  ob- 
scure case  of  gastric  or  intestinal  diseases. 

Profuse  haemorrhages  presuppose  the  erosion  of  a  larger  vessel ; 
the  blood  acts  as  an  emetic  on  the  stomach,  so  that  it  empties  itself 
of  its  contents.  Many  patients  have  a  distinct  and  positive  premo- 
nition in  the  form  of  flashes  of  heat,  epigastric  pulsation,  fullness  in 
the  region  of  the  stomach,  and  great  and  apparently  groundless  rest- 
lessness, as  in  the  case  described  at  the  beginning  of  this  lecture. 
The  time  during  which  the  blood  remains  in  the  stomach  varies, 
and  with  this,  consequently,  the  appearance  of  the  vomited  masses. 
In  some  cases  we  find  bright-red  clots,  in  others  dark  brownish-red 
masses,  while  in  the  great  minority  of  cases  it  presents  the  appear- 
ance of  coffee-grounds.  Part  of  the  blood  passes  into  the  intestines. 
This  is  the  rule  in  the  smaller  haemorrhages  which  do  not  lead  to 
vomiting  ;  the  blood  mingles  with  the  rest  of  the  intestinal  contents 
and  is  not  recognizable  in  the  fseces,  or  is  overlooked.  In  the  case 
of  larger  haemorrhages,  or  if  the  ulcer  is  situated  in  the  duodenum, 
the  evacuations  consist  of  tarry,  very  offensive  masses.  The  pres- 
ence of  blood  in  the  vomit  can,  as  a  rule,  be  readily  established  with 
the  naked  eye ;  it  can  always  be  easily  discovered  with  the  micro- 
scope or  spectroscope,  or  by  means  of  Heller's  blood-test.  "We  must 
not  forget  that  confusion  may  arise  if  the  patient  has  partaken  of 
red  wine,  cacao,  colored  medicines,  cinnamon,  or  real  coffee-grounds ; 
but  a  glance  through  the  microscope  will  readily  settle  this  ques- 
tion. 

The  estimation  that  haematemesis  occurs  in  50  per  cent  of  the 
cases  is  rather  too  high  than  too  low.  Brinton  gives  29  per  cent ; 
Witte,  of  Copenhagen,  found  it  100  times  in  339  cases ;  and  Ger- 


SYMPTOMS  OP  GASTRIC  ULCER.  247 

hardt  saw  it  in  47  per  cent  of  his  cases  :  *  so  we  may  assume  that 
considerably  more  than  half  the  patients  do  not  have  hsematemesis. 

It  scarcely  needs  to  be  mentioned  that  we  must  guard  against 
confusion  with  hsemorrhage  from  the  oesophagus,  gums,  or  after 
the  extraction  of  a  tooth,  or  that  we  must  not  forget  that,  as 
I  have  already  stated,  hsemorrhage  may  occur  in  the  initial  stages  of 
cirrhosis  of  the  liver,  in  disturbances  of  the  circulation,  in  aneurism, 
etc.  In  the  first  of  the  above,  however,  it  may  sometimes  be  very 
difficult,  for  profuse  haemorrhages  may  occasionally  take  place  from 
varicose  venous  plexuses  in  the  oesophagus,  occurring  in  the  aged  or 
in  the  phlebectasise,  which  form  part  of  the  collateral  circulation 
developed  in  cirrhosis  of  the  liver,  and  which  have  repeatedly  given 
rise  to  fatal  haemorrhages.  Ulcer  of  the  oesophagus  may  also  lead 
to  hsematemesis.  The  bloody  masses  in  haemorrhage  from  gastric 
nicer  contain  no  specific  tissue  elements,  and  the  blood-corjouscles 
are  present  in  such  excess  that  the  cellular  elements  of  the  gastric 
mucous  membrane  appear  only  sparingly,  or  not  at  all. 

The  diagnosis  of  admixture  of  blood  with  the  faeces  is  at  times 
more  difficult,  for  here  the  blood-cells  are  nearly  always  so  changed 
in  their  passage  through  the  intestine  that  they  lose  their  character- 
istic form.  Although  this  is  not  usual  in  larger  haemorrhages,  it  is 
in  smaller,  especially  if  preparations  of  mercury  or  sulphur  [or  iron] 
have  been  prescribed,  which  of  themselves  imjjart  a  dark  color  to 
the  stools. 

When  larger  haemorrhages  have  occurred,  the  danger  of  their 
recurrence  hangs  over  the  patient's  head  like  the  sword  of  Damo- 
cles, and  in  a  twofold  manner  :  First  of  all,  repeated  haemorrhages 
occur  in  the  course  of  the  day,  even  several  times  during  the  same 
day,  or  at  short  intervals,  say,  during  a  week.  Then  we  must 
assume  that  there  are  recurrences  from  the  same  vessel  which 
was  first  opened.  Secondly,  after  a  pause  of  months,  or  even  years, 
fresh  haematemesis  appears.  Its  return  may  be  due  to  a  tendency 
of  the  individual  to  this  kind  of  haemorrhage.  In  order  to  form 
any  idea  at  all  why  in  certain  persons  extensive  ulcers  which  must 
necessarily  have  involved  large  vessels  in  their  growth  run  their 

*  C.  Gerhardt.     Loc.  cit. 


248  DISEASES  OP  THE  STOMACH. 

course  without  lissmorrliage,  and  others  are  marked  by  such  profuse 
ligemorrhage,  we  must,  in  my  opinion,  assume  a  certain  predispo- 
sition to  a  deficiency  in  the  fibrinoplastic  power  of  the  blood,  and 
with  this  an  insufficient  or  ineffectual  formation  of  thrombi.  It  oc- 
casionally appears,  too,  as  if  the  thrombi  after  being  formed  w^ere 
very  loosely  attached  and  could  be  quite  easily  displaced,  as  soon  as 
the  heart's  action  exceeded  its  normal  strength.  Thus  I  have  twice 
seen  a  hagmorrhage  recur  after  a  long  period  of  quiescence,  caused 
by  the  patients,  who,  thinking  themselves  well,  had  indulged  in 
strong  alcoholic  beverages,  although  only  in  small  quantities. 

Small  haemorrhages  have  no  influence  on  the  condition  of  the 
patient,  except  psychically  ;  larger  haemorrhages,  especially  if  recur- 
ring at  short  intervals,  lead  to  a  high  degiee  of  anaemia  and  its 
consequences.  Waxy  pallor  of  the  skin,  small,  rapid  pulse,  slight 
febrile  movements,  complete  anorexia,  ringing  in  the  ears  and  ver- 
tigo, transient  mild  delirium,  and  even  complete  loss  of  conscious- 
ness may  occur.  Subsultus  tendinum  and  convulsions  in  the  ex- 
tremities have  even  been  observed.  In  sjDite  of  this,  as  a  rule,  the 
patients  rally  comparatively  rapidly,  and  under  appropriate  treat- 
ment soon  tend  to  regain  their  lost  powers.  Nevertheless,  I  have 
seen  a  number  of  cases  in  which  the  patients  finally  died  with  the 
symptoms  of  progressive  pernicious  anaemia,  the  number  of  the 
red  blood-corpuscles  sinking  to  two  millions  per  cubic  centimetre 
(the  normal  being  five  millions)  and  the  quantity  of  haemoglobin  to 
25  to  30  per  cent. 

Immediately  fatal  cases  of  gastric  haemorrhage  from  the  vessels 
of  the  stomach  are  comparatively  rare.  In  most  the  cause  has  been 
perforation  of  the  ulcer  (see  page  249),  and  the  involvement  of  the 
splenic  or  pancreatic  artery,  the  portal  vein  or  the  left  heart.  Cru- 
veilhier  pictures  a  case  in  which  the  stomach  was  distended  with 
fluid,  brownish-red  blood.  Budd  saw  a  case  in  which  not  only  the 
stomach  but  also  the  entire  intestinal  tract  was  full  of  blood,  and  in 
which  the  patient  had  bled  to  death  into  his  own  body.  A  case 
reported  by  Finny  is  interesting :  * 


*  Pinny.     Ulcer  of  the  Stomach  opening  in  the  Left  Ventricle  of  the  Heart. 
Brit.  Med.  Jour.,  1886,  i,  p.  1103. 


SYMPTOMS  OP   GASTRIC   ULCER.  249 

A  young  man,  niueteen  years  of  age,  in  ■vvhom  phthisis  had  been  sus- 
pected, and  who  for  some  time  had  had  hectic  fever,  died  suddenly.  There 
were  no  symptoms  of  stomach  trouble.  Vomiting  did  not  occur,  not 
even  immediately  before  death.  The  stomach  and  intestines  down  to  the 
anus  were  found  full  of  fluid  blood.  The  stomach,  diaphragm,  pericar- 
dium, and  myocardium  had  all  become  adherent  to  one  another.  A  small 
cannular  communication  led  into  the  left  ventricle  ;  otherwise  its  muscle 
was  normal,  and  was  found  to  have  undergone  granular  degeneration 
only  in  the  neighborhood  of  the  perforation.  The  ulcer  in  the  stomach 
was  situated  on  the  anterior  wall,  and  measured  one  inch  and  a  quarter 
in  length  by  three  quarters  of  an  inch  in  width. 

A  small  aneurism  of  the  gastric  artery  was  the  cause  of  death  in 
a  case  reported  by  Powell.*  The  ulcer  was  situated  near  the  cardia 
on  the  lesser  curvature,  and  in  tlie  center  was  a  ruj)tured  aneurism 
of  the  size  of  a  pea,  the  profuse  heemorrbage  from  which  caused 
the  death  of  the  patient  in  a  few  minutes. 

Referring  to  the  fourth  group  mentioned  above  [page  243],  we 
see  that  bsemorrhages  may  occur  without  any  previous  indication  of 
a  gastric  ulcer,  and  in  fact  these  bave  frequently  been  observed.  I 
wish  to  again  recall  to  your  memory  the  case  described  at  the  com- 
mencement of  this  lecture  as  belonging  in  this  category.  However, 
in  this  patient  vague  symptoms  of  a  grave  illness  preceded  tbe  fatal 
hsemorrhage,  while  in  other  cases  it  has  killed  apparently  healthy 
persons  with  alarming  and  unexpected  suddenness.  In  this  connec- 
tion a  case  of  hsemorrhage  from  the  intestines  described  by  Pois- 
son  f  is  of  diagnostic  interest ;  the  bleeding  appeared  during  conva- 
lescence from  an  attack  of  typhoid,  and  might  have  occasioned  its 
being  mistaken  for  a  typhoid  haemorrhage. 

A  severe  complication  of  this  disease  is  produced  by  the  perfo- 
ration of  the  ulcer  and  the  involvement  of  the  neighhoring  organs. 
When  the  digestive  process  has  reached  the  serous  layer  of  the  gas- 
tric wall,  and  has  involved  one  of  the  neighboring  solid  organs 
(among  which  I  here  include  the  coils  of  intestine),  it  manifests  itself 
occasionally  by  a  localized  sensation  of  pain,  referable  to  the  posi- 
tion of  the  affected  viscus.  Most  frequently,  however,  it  runs  its 
course  without  any  outward  manifestation,  so  that  only  when  dis- 
turbances of  function  appear  in  the  organs  involved  do  we  recog- 

*  Powell.     Transact.  Pathol.  Soc.  [London],  vol.  sxix,  p.  133. 
t  Poisson.    Bull,  de  la  Soc.  anat.  de  Paris,  Febr.,  1855. 


250  DISEASES  OF  THE  STOMACH. 

nize  tlie  fact  that  they  are  similarly  affected,  Qr  haemorrhages 
may  occur  from  the  larger  vascular  trunks,  especially  in  the  pancreas 
and  spleen,  which  are  naturally  in  no  way  to  be  distinguished  from 
those  already  considered. 

I  do  not  consider  it  essential  to  give  a  detailed  account  of  the 
intercurrent  affections  possible  here,  and  which  I  have  already  re- 
ferred to  above,  although  the  literature  of  the  past  fifty  years  is  full 
of  rejDorts  which  exhaust  all  such  complications.  We  can  readily 
conceive  of  the  occurrences  in  question  on  calling  to  mind  the  to- 
.pography  of  the  stomach  and  its  relations  to  the  surrounding  organs. 
The  most  interesting  is  the  perforation  through  the  diaphragm 
[sometimes  giving  rise  to  diaphragmatic  hernia]  and  pericardium 
into  the  left  heart,*  with  pneumo-pericarditis,  or  into  the  medias- 
tinum, with  cutaneous  emphysema  and  collection  of  inflammable 
gases.  West  f  describes  a  case  in  which  the  ulcer  extended  to  the 
portal  vein,  and  caused  death  from  pylephlebitis.  Perforation 
into  the  pleura  :j:  can  be  diagnosticated  if  it  causes  pneumothorax 
and  suppurative  pleuritis,  or  if  it  leads  to  direct  communication 
with  the  lungs,  and  the  coughing  up  of  particles  of  food,  which  not 
only  may,  but  actually  has  occurred. 

I  have  already  spoken  of  perforation  into  the  colon  and  the  re- 
sulting lienteric  diarrhoea,  in  discussing  perforation  due  to  cancer- 
ous ulceration.  Perforation  into  the  abdominal  cavity  may  develop 
variously.  In  fortunate  cases  there  is  a  preceding  adhesive  inflam- 
mation between  the  stomach  and  the  neighboring  intestinal  wall 
and  omentum,  thus  forming  a  cavity  representing  a  sac  inclosed  in 
a  sac,  which  prevents  the  escajDC  of  the  gastric  contents  into  the 
abdominal  cavity.  Then  signs  of  irritation  of  the  peritonaeum 
appear ;  circumscribed  pain  and  distention  of  the  upper  part  of  the 
abdomen,  together  with  fever,  and  sometimes  frequent  vomiting. 
If  the  adhesions  are  more  extensive  they  may  result,  as  in  the  case 

*  [Oser  has  described  a  case  in  which,  although  the  left  ventricle  was  eroded, 
the  patient  survived  two  days.  The  opening  was  closed  during  the  systole  and 
only  open  during  the  diastole ;  the  patient  thus  gradually  bled  to  death.  Addi- 
tional cases  are  quoted  by  Welch  (Pepper's  System  of  Med.,  vol.  ii,  p.  508). — Tr.] 

t  S.  West.     Pathol.  Transact.,  p.  147.     London,  1890. 

X  [In  a  case  reported  by  Miiller,  lumbricoid  worms  were  found  in  the  pleural 
cavity.    Memorabilien,  xvii,  October,  1873.     Quoted  by  Welch,  loc.  cit. — Tr.] 


PERFORATION  Oi"'  GASTRIC  ULCER.  251 

of  Buck],  wliicli  I  have  already  mentioned,  in  complete  interference 
with  the  functions  of  the  intestine,  thns  leading  to  permanent  ob- 
struction, progressive  marasmus,  and  death. 

Perforation  into  the  peritoneal  cavity  is  by  far  the  most  fre- 
quent, however,  either  with  or  without  previous  adhesions  and  for- 
mation of  abscess.  It  may  follow  slowly  and  gradually,  or,  rather, 
the  escape  of  the  gastric  contents  may  be  slow.  In  such  cases  sac- 
culated abscesses  may  form,  which  remain  encapsulated,  or  burst 
later  on,  and  cause  general  peritonitis.  As  a  rule,  though,  the  per- 
foration occurs  quite  suddenly,  without  any  warning  or  symptoms 
referable  to  it.  The  patients  suddenly  experience  severe  pain  in  the 
abdomen,  causing  them  to  collapse  to  a  certain  extent.  This  ap- 
pears without  cause,  or  after  a  preceding  traumatism,  such  as  an 
accidental  blow,  or  after  leaning  on  the  edge  of  a  table  or  window- 
sill,  after  riding,  after  a  hearty  meal,  or  after  vomiting.  In  a  short 
time  the  clinical  picture  of  peritonitis  due  to  perforation  is  devel- 
oped :  distention  of  the  abdomen,  severe  pain  even  on  the  slightest 
touch,  vomiting,  singultus,  facies  Hippocratica,  small  pulse,  and 
finally  death.  Yet,  as  in  the  case  recorded  at  the  commencement  of 
this  lecture,  the  perforation  may  occur  without  the  appearance  of 
any  of  these  signs.  Inasmuch  as  the  patient  had  practically  taken 
no  food  for  three  days  previously,  the  stomach  in  this  case  was  empty 
both  of  food  and  air[?],  and  consequently  the  perforation  of  the 
ulcer  was  accompanied  only  by  the  symptoms  of  profound  shock — 
unconsciousness,  Cheyne-Stokes  respiration,  extremely  small  pulse, 
cold  skin,  etc. — while  the  abdomen  was  neither  markedly  distended 
nor  very  painful.* 

Such  perforations  may  also  be  caused  by  convulsive  contractions 
of  the  stomach  after  vomiting,  induced  either  by  drugs  or  by  the 
introdufction  of  the  finger  into  the  throat,  as  many  patients  are 
fond  of  doing  in  order  to  produce  vomiting  or  belching,  or  after 
the  introduction  of  the  stomach-tube.  Faberf  describes  a  case  of 
perforation  after  vomiting  brought  on  by  the  patient.     According 

*  Even  unconscious  individuals  react  still  to  severe  painful  sensations. 

f  Faber.  Emphysem  des  Mediastinums  und  der  ausseren  Haut  in  Folge  einer 
Perforation  eines  Magengeschwiirs.  Wiirttemb.  med,  Correspondenzbl.,  1885, 
No.  40. 


252  DISEASES  OF  THE  STOMACH. 

to  Bouilleaud,*  the  act  of  defecation,  completed  in  the  usual  manner, 
may  give  rise  to  perforation. 

In  the  practice  of  one  of  my  colleagues  I  have  myself  recently  observed 
a  case  of  perforation  of  an  ulcer  which  had  caused  stenosis  of  the  pylorus; 
the  opening-  was  the  size  of  a  cheriy-pit.  This  occurred  during  the  even- 
ing, after  lavage  of  the  stomach,  which  had  at  one  time  been  recommended 
by  me  on  account  of  the  marked  dilatation  of  the  stomach  and  accunmla- 
tion  of  its  contents.  Immediately  afterwai'd  the  emaciated  and  miserable 
patient  complained  of  severe  abdominal  pain  and  distention,  and  died  in 
collapse  that  very  night.  At  the  autopsy  which  I  held  I  found  the  condi- 
tion described  above,  and  I  here  show  you  the  specimen.  We  found  air 
and  blackish-brown  stomach -contents  in  the  abdominal  cavity.  The  stom- 
ach is  enormously  dilated,  and  the  pylorus  is  so  narrow  that  a  pencil  can 
scarcely  be  passed  through  it.  Immediately  above  this  hes  the  ulcer.  It 
is  about  the  size  of  a  2-mark  [50-cent]  piece,  with  wall-like  and  thickened 
(carcinomatous)  edges,  and  in  the  center  is  seen  the  circular  perforation 
with  very  smooth,  sharp  contour,  which  is  not  at  all  ragged  or  torn,  and 
which  in  no  way  suggests  a  recent  wound.  Inasmuch  as  my  colleague 
used  a  soft  rubber  tube,  taking  all  necessary  precautions,  a  direct  lesion 
caused  by  it  may  be  excluded.  My  explanation  of  the  case  is  rather  that 
a  slight  adhesion  had  taken  place  and  was  broken  up  by  the  marked  trac- 
tion on  the  gastric  or  abdominal  walls  which  always  accompanies  the 
washing  out  of  the  stomach. 

I  need  scarcely  mention  that  this  experience  has  only  strengthened  my 
repeatedly  expressed  view  of  the  necessity  for  caution  in  the  use  of  the 
sound,  etc. 

Cases  which  recover  from  such  perforations  are  among  tlie  great- 
est rarities.f  We  really  can  not  speak  of  recovery  in  the  true  sense 
of  the  word,  for  the  adhesions  of  the  intestines,  wdiich  are  produced 
in  the  most  favorable  cases,  lead  to  chronic  illness,  and  death  occurs 
in  a  comparatively  short  time  from  progressive  disturbance  of  nu- 
trition. Sudden  perforations  have  repeatedly  caused  suspicion  of 
poisoning,  and  have  led  to  erroneous  accusations. 

["  Gastro-cutaneous  iistulse  are  a  rare  result  of  the  perforation  of 


*  Bouilleaud.     Arch,  de  med.,  i.,  p.  534. 

f  [Such  a  case  has  recently  been  published  by  Hall.  Case  of  Perforating  Gas- 
tric Ulcer,  Peritonitis.  Recovery.  Brit.  Med.  Jour.,  January  9,  1892.  The  writer 
found  only  six  reported  cases  of  recovery  after  peritonitis  from  perforating  gas- 
tric ulcei".  Three  recovered  completely ;  three  died  in  the  course  of  subsequent 
attacks;  autopsies  verified  the  diagnoses.  The  treatment  was  expectant — i.  e., 
opium  and  rectal  alimentation.  The  good  result  was  attributed  to  the  fact  that 
the  perforation  occurred  four  hours  after  eating,  when  the  stomach  was  empty. 
— Tr.] 


SYPHILIS  AND    ULCER.  253 

gastric  ulcer.*  The  external  opening  is  most  frequently  in  the  um- 
bilical region,  but  it  may  be  in  the  epigastric  or  in  the  left  hypo- 
chondriac region  or  between  the  ribs."] 

The  form  of  the  cicatrization  is  of  great  importance.  It  is  very 
apparent  that  cicatricial  contraction  may  lead  to  the  severest  disturb- 
ances of  the  functions  of  the  stomach,  of  which  one,  dilatation  fol- 
lowing cicatricial  stenosis  of  the  pylorus,  has  already  been  discussed. 
In  these  cases  a  well-marked  and  characteristic  clinical  j^icture  is  de- 
veloped. In  other  cases  the  cicatricial  contraction  leads  to  traction 
on  the  nerves  in  the  gastric  wall,  to  deformities  of  the  viscus,  to  the 
sliutting  out  of  larger  portions  of  the  muscular  coat,  or  to  adhesions 
with  the  neighboring  organs ;  the  result  is  gastralgias,  or  disturb- 
ances of  function,  which  manifest  themselves  as  "  dyspepsias "  of 
various  kinds.  As  a  rule  the  primary  cause  of  these  "  dyspepsias  "  is 
very  difficult  to  discover ;  a  cure  is  usually  or  nearly  always  impossi- 
ble. It  is  not  uncommon  for  such  patients  to  be  regarded  as  "  nerv- 
ous dyspeptics."  If  saccular  dilatations  form,  and  if  it  happen  that 
for  some  reason  lavage  is  used  later  on,  the  remarkable  phenomenon 
may  appear  that  the  stomach  apparently  can  not  be  emptied.  The 
water,  to  be  sure,  comes  away  almost  clear  after  a  time,  but  it  sud- 
denly becomes  turbid  again ;  this  may  be  repeated  several  times. f 
In  such  cases  we  either  have  the  condition  described,  or  an  insuffi- 
ciency of  the  pylorus,  permitting  regurgitation  of  the  contents  of  the 
duodenum  into  the  stomach. 

Syphilis  and  Ulcer. — As  early  as  1838  Andral  inquired  why  syph- 
ilitic manifestations  could  not  break  out  on  the  mucous  membrane 
of  the  stomach  as  well  as  on  that  of  the  mouth.  Since  that  time  the 
question  has  been  frequently  discussed,  and  a  number  of  more  or  less 
convincing  observations  have  been  published  by  Goldstein,  Hiller, 
Yirchow,  Leudet,  Lanceraux,  Fauvel,  Klebs,  and  Cornil.     Only  two 


*  ["  Of  the  25  cases  of  gastro-eutaneous  fistulsB  collected  by  Murchison,  18  were 
the  result  of  disease.  In  12  of  these  cases  the  probable  cause  was  simple  gastric 
ulcer  (Med.-Chir.  Transact.,  London,  1858,  vol.  xli,  p.  11).  Middeldorpf  says  that 
among  the  internal  causes  of  the  47  cases  of  external  gastric  fistulas  which  he  tabu- 
lated, simple  ulcer  of  the  stomach  played  an  important  role  (Wiener  med.  Wochen- 
schr..  1860).    Welch,  loc.  cit,  vol.  ii,  p.  508.~Tr.] 

f  Gr.  Scherf — Beitrage  zur  Lehre  von  der  Magendilatation ;  Inaug.  Dissert., 
Gottingen,  1879 — also  observed  this. 


254  DISEASES  OP  THE  STOMACH. 

cases  of  the  simultaneous  appearance  of  gumma  and  ulcer  liave  been 
observed.  Other  observers  (Frerichs,  Drozda,  Murchison,  Chvos- 
tek)  found  scars  in  the  stomach  coincidentlj  with  general  syphilis. 
Among  100  cases  of  ulcer,  Engel  found  previous  sy]3hilis  in  10 
per  cent,  Lang  found  it  in  20  per  cent,  while  Julien*  justly 
expresses  himself  with  great  reserve  on  this  subject.  It  must 
always  remain  questionable  in  two  diseases,  as  common  as  those  under 
discussion,  whether  we  are  dealing  with  cause  and  effect,  or  with  an 
accidental  coincidence,  especially  since  we  are  by  no  means  able  in 
every  case  to  avoid  confounding  it  with  an  ulcerating  gumma.  Here 
the  result  of  specific  treatment  can  alone  be  conclusive.  A  number 
of  such  cases  have  been  reported,  for  instance  by  Hiller  f  and  by 
Galliard, :{:  although  the  latter,  who  has  published  the  latest  mono- 
graph on  the  subject,  admits  that  they  can  not  be  positively  proved. 
At  any  rate,  syphilitic  ulcers  do  not  show  specific  symptoms,  l^ev- 
ertheless,  it  is  advisable  to  use  specific  treatment  in  cases  showing  the 
signs  of  gastric  ulcer  together  with  the  existence  of  syphilis. 

Tuberculosis  and  Ulcer. — As  is  well  known,  tubercular  ulcerations 
of  the  intestinal  canal  are  common,  but  they  do  not  occur  very  fre- 
quently with  ulcer  of  the  stomach ;  this  may  be  because  the  germi- 
cidal action  of  the  gastric  juice  jDrevents  the  proliferation  of  the 
bacilli  which  may  be  introduced  in  swallowed  sputum,  or  in  the 
blood.  The  occurrence  of  single  tubercular  ulcers  of  the  stomach 
without  further  implication  of  the  digestive  tract  is  very  rare.  (See 
p.  241.)  There  are  only  a  few,  and  in  part,  disputable  cases  on  record 
collected  by  Marfan,*  in  a  study  of  the  gastric  disturbances  in  phthi- 
sis pulmonalis.  Tubercular  ulcers  of  the  stomach  present  no  specific 
symptoms.  Sudden  death  from  hasmatemesis  due  to  the  involve- 
ment of  vessels  has  also  been  observed  in  these  cases.  [Musser  || 
claims  that  this  is  the  rule.] 

Diagnosis. — When  all  the  classical  symptoms  are  present  the  diag- 
nosis of  chronic  gastric  ulcer  is  easy  and  scarcely  to  be  mistaken ; 

*  Julien.     Traite  des  maladies  veneriennes.     Paris,  1886,  p.  880. 
f  Hiller.     Monatschr.  f.  prakt.  Heilkunde,  1883. 

X  Galliard,  loc.  cit. 

*  B.  Marfan.    Troubles  et  lesions  gastriques  dans  la  phthisis  pulmonaire.    Paris, 
1887. 

II  \_Loc.  cit.l  ^ 


DIAGNOSIS  OB"^  GASTRIC   ULCER. 


255 


while  if  this  be  not  the  case  it  can  only  be  made  approximately,  or 
not  at  all.  Where  it  deviates  from  its  typical  course  there  are  prac- 
tically two  other  diseases  of  the  stomach,  the  symptoms  of  which 
resemble  those  of  gastric  ulcer — i.  e.,  gastralgia  or  gastrodynia, 
occurring  as  the  expression  of  nervous  disturbance,  and  carcinoma. 
A  good  survey  of  the  symptoms  of  the  diseases  in  question  may  be 
obtained  by  arranging  them  in  parallel  columns,  as  "Walshe  has 
done  in  his  celebrated  treatise  on  cancer.* 


Nervous  Gastbalgia. 


Gastric  Ulcer. 


Gastric  Cancer. 


Tongue  variable,  often 
pale,  with  indented 
edges. 


Frequent      helching 
odorless  gas. 


of 


No  change  of  the  iaste  in 
the  mouth.  Frequent 
dryness  in  the  mouth ; 
may  have  salivation. 

Appetite  irregular  and  ca- 
pricious. 


Variable  sensations  in  the 
stomach,  at  times  hot 
and  at  others  cold. 


Pain  entirely  irregular 
and  not  dependent  up- 
on eating ;  frequently 
eased  by  this  or  by 
pressure  on  the  stom- 
ach. Puncta  dolorosa 
over  the  intestinal 
plexus. 

Chemistry  of  digestion 
not  essentially  altered. 


Epigastric  pulsation. 


Tongue  dry  and  red,  with 
a  white  stripe  down  the 
middle ;   or   smooth  and 

•  moist,  or  lightly  coated. 

Belching  rare ;  or  sour  re- 
gurgitation with  heart- 
burn. 

Taste  unchanged. 


Appetite  good  between  the 
attacks.     Thirst. 


Burning  in  the  stomach. 
Circumscribed  boring 
pains,  frequently  radiat- 
ing to  the  back. 

Pains  rare  when  the  stom- 
ach is  empty ;  chiefly 
after  eating,  or  after 
movements  or  positions 
which  cause  traction  on 
the  stomach.  Increased 
by  pressure. 


Digestion  of  starch  foods 
frequently  retarded.  Di- 
gestion of  meat  normal  or 
even  too  rapid.  Hyper- 
acidity the  rule. 


Tongue  pale  and  furred. 


Frequent  fetid  belching. 


Pasty,  insipid  taste. 


Appetite  diminished  or  en- 
tirely absent.  Repug- 
nance to  meat  shown 
early  in  the  disease. 

Feeling  of  oppression,  draw- 
ing, and  pain  of  variable 
character.  Later,  pain  in 
the  shoulder. 

Continuous  dull  pain,  at 
times  becoming  paroxys- 
mal. Frequently  produced 
or  increased  by  pressure. 


Digestion  insufficient ;  as  a 
rule,  deficiency  of  free 
hydrochloric  acid.  For- 
mation of  organic  prod- 
ucts of  decomposition. 

Epigastric  pulsation  only 
seen  with  marked  emacia- 
tion. 


*  [The  Nature  and  Treatment  of  Cancer.    London,  1846,  p.  289.] 


256 


DISEASES  OP  THE  STOMACH. 


Nervous  Gastealgia. 


Gastric  Ulcer. 


Gastric  Cancer. 


Vomiting  variable :  some- 
times only  mucus,  some- 
times more  or  less  di- 
gested stomach  -  con- 
tents ;  seldom  with 
bile. 


No  hcematemesis,  except- 
ing in  unusual  acci- 
dental complications. 


Obstinate  constipation  al- 
ways present  to  a  great- 
er or  lesser  degree.  ISToi'- 
mal  stool  very  rare.  At 
times  watery,  mucous 
evacuations,  the  so- 
called  i^seudo-diarrhoea. 

No  fever. 


Complexion  pale,  rarely 
fresh.  Cutaneous  cir- 
culation normal. 


Occurs  at  all  ages.  Com- 
moner in  women  than 
in  men.  Frequently  in 
combination  with  hys- 
terical symptoms. 


No  tumor  can  be  palpated 
unless  in  the  rare  and 
exceptional     cases     in 


Vomiting  usually  immedi- 
ately or  within  a  short 
time  after  eating ;  fre- 
quently the  first  symp- 
tom of  the  disease.  Very 
rarely,  hyperacid  vomit- 
ing from  an  empty  stom- 
ach. 


Vomiting  of  clear  blood  or 
coffee-ground  masses.  As 
a  rule,  frequently  repeat- 
ed within  a  short  time. 
At  times  very  profuse, 
with  intense  anaemia  and 
collapse.  Comparatively 
rapid  recovery.  Bloody 
stools. 

Stool  variable.  Diarrhoea 
due  to  intestinal  irrita- 
tion not  uncommon.  Li- 
enteric  diarrhoea  after 
perforation  into  the  colon. 


Slight  febrile  movement, 
but  only  in  the  presence 
of  adhesive  inflammation 
caused  by  perforation  of 
the  ulcer;  or  in  connec- 
tion with  larger  haemor- 
rhages. 

Complexion  commonly 
fresh,  only  anaemic  after 
severe  losses  of  blood. 
Frequently  the  visible 
mucous  membranes  and 
even  the  cheeks  are  slight- 
ly cyanotic.  Another 
group  of  patients  is  chlo- 
rotic. 

Most  frequent  in  middle- 
aged  patients.  Rare  in 
children.  Spirits  varia- 
ble, frequently  much  de- 
pressed. 


Round,  egg-shaped  tumor 
to  the  right  of  the  mid- 
line, if  the  ulcer  is  situ- 


Violent  and  frequent  vom- 
iting, often  periodic,  at 
times  from  an  empty 
stomach.  Mucous;  if  acid, 
it  is  owing  to  organic 
acids.  Always  appears 
first  in  the  course  of  other 
dyspeptic  troubles.  Con- 
sists of  slightly  digested 
food  and  occasionally  can- 
cer-cells. 

Blood  more  often  decom- 
posed than  recent.  Quan- 
tity usually  small.  When 
once  commenced,  fre- 
quently recurs  and  with- 
out specially  long  inter- 
vals. 


Obstinate  constipation  al- 
most constant.  Lienteric 
diarrhoea  after  perfora- 
tion into  the  colon. 


Fever  rare.  When  present, 
only  seen  toward  the  end 
of  life. 


Complexion  pale  and  yel- 
lowish. Skin  dry  and  re- 
laxed.    Marked  cachexia. 


Most  frequent  between  forty 
and  sixty  years.  Spirits 
depressed  and  despond- 
ent, but  remarkably  less 
despairing  than  in  severe 
cases  of  ulcer. 

Tumor  variable  in  size  and 
form :  knobbed  or  smooth ; 
can  readily  be  palpated; 


DIAGNOSIS  OP  GASTRIC    ULCER. 


257 


Nervous  Gastralgia. 


Gastric  Ulcer. 


Gastric  Cancer. 


which  foreign  bodies, 
such  as  hair,  etc.,  are 
introduced. 


[Hydrochloric  acid  pres- 
ent and  usually  in- 
creased in  amount.] 

No  symptoms  of  perfora- 
tion. 


ated  at  the  pylorus  and 
is  followed  by  hypertro- 
phy. In  old  ulcers  with 
a  firm  base  and  thickened 
bordex' — or  in  circum- 
scribed encapsulated  per- 
forations, or  in  case  of 
adhesions  with  the  head 
of  the  pancreas,  the  left 
lobe  of  the  liver  or  the 
spleen — a  tumor  may  at 
times  be  palpated.  Posi- 
tion not  changed  by  re- 
spiratory movements. 

Hydrochloric  acid  present 
and  increased  in  amount. 


Perforation  into  the  neigh- 
boring organs,  with  its 
characteristic  signs  ap- 
pearing even  after  an  ap- 
parently short  duration 
of  the  disease,  or  without 
so  much  as  a  premoni- 
tion. 


usually  can  be  moved 
without  resistance  ;  at 
times  its  position  changes 
with  respiration.  Sec- 
ondary glandular  enlarge- 
ments.    Metastases. 


In  the  majority  of  cases  no 
hydrochloric  acid. 


Perforation  or  implication 
of  surrounding  organs 
only  after  the  disease  has 
existed  for  some  time.* 


I  hope  that  this  table  may  be  of  service  in  establishing  a  differ- 
ential diagnosis.  However,  sharp  as  the  distinction  between  the 
three  pictures  may  appear  on  paper,  we  find  often  enough  in  prac- 
tice that  just  the  most  important  symptoms  are  absent,  or  so  com- 
bined with  one  another,  or  so  vaguely  manifested,  that  an  exact 
diagnosis  can  not  possibly  be  made.  This  applies  especially  to  the 
early  stages  of  the  ulcerative  process.  Up  to  the  present  time  it 
was  well-nigh  impossible  to  differentiate  these  conditions  from  the 
many  forms  of  dyspepsia,  as  long  as  they  presented  only  more  or 
less  marked  general  disturbances  of  nutrition,  as  long  as  no  typical 
gastralgic  attacks  occurred,  and  especially  as  long  as  every  trace  of 
haematemesis  was  absent.  I  regard  the  demonstration  of  increased 
acidity  as  a  marked  advance  toward  the  recognition  of  this  condition, 
and  it  enables  us  to  make  an  early  diagnosis.  It  is  just  in  these 
cases  that  I  consider  it  especially  valuable,  although  we  must  not 
forget  that  we  undoubtedly  find  exceptions  to  this  rule.     I  have 


*  [See  also  E.  Kollmar,  Zur  Dififerentialdiagnose  zwischen  Magengeschwiir  und 
Magenkrebs.     Berl.  klin.  Wochensehr,,  Bd.  xxviii,  S.  119,  146. — Tr.] 


258  DISEASES  OF  THE  STOMACH. 

already  given  you  an  example  of  such  an  exception  in  the  history  of 
the  case  on  page  211,  and  anotlier  may  not  be  amiss  at  this  place. 

I  here  present  to  you  tlie  patient  in  question,  a  man,  forty-one 
years  of  age,  who  has  suffered  from  repeated  gastric  haemorrhages, 
and  whose  history  and  examination  permit  no  doubt  in  the  diag- 
nosis of  ulcer  of  the  stomach.  He  came  here  about  three  weeks 
ago  to  take  the  Leube-Ziemssen  rest-cure.  The  contents  of  his 
stomach  have  been  examined  three  times,  with  the  following  re- 
sults :  70  per  cent  on  March  8,  58  per  cent  on  March  20,  and 
66  per  cent  on  March  25,  1S8T.  Here  I  show  you  the  filtrate 
five  hours  after  a  light  dinner ;  on  titration  to-day,  April  1,  1887, 
the  acidity  is  63  per  cent.*  I  have  purposely  selected  this  form  of 
test-meal  in  order  that  you  may  see  that  no  difference  exists  be- 
tween the  test-breakfast  and  test-dinner.  No  lactic  or  fatty  acids  are 
present.  Even  regarding  the  value  of  70,  which  was  first  found,  as 
lying  on  the  boundary-line  of  hyperacidity,  the  others  are  far  below 
it,  and  we  therefore  see,  as  I  have  said  above,  that  hyperacidity  is 
not  an  absolute  attribute  of  ulcer  of  the  stomach,  and  that  a  nega- 
tive result  is  accordingly  not  decisive  in  establishing  a  diagnosis.  I 
do  not  mean  by  this  to  belittle  the  value  of  positive  results,  for 
establishing  which  Eiegel  deserves  great  credit ;  nevertheless,  the 
simultaneous  presence  of  the  three  classical  symptoms — typical  gas- 
tralgia,  hsematemesis,  and  bloody  stools,  together  with  absence  of 
tumor  and  cachexia — still  remains  the  most  positive  means  of  mak- 
ing diagnosis.  Yet  I  have  seen  cases  of  undoubted  gastric  ulcer 
with  great  loss  of  strength ;  and,  on  the  other  hand,  cases  of  cancer 
of  the  stomach  in  which  the  strength  and  general  condition  were 
unusually  good.  At  times  we  can  only  make  the  diagnosis,  as 
Leube  also  says,  by  the  success  or  failure  of  specific  treatment  for 
ulcer.  A  special  difficulty  in  diagnosis  may  be  caused  by  the  above- 
mentioned  tumor-like  cicatrization,  and  where  neighboring  organs 
have  been  drawn  into  the  base  of  the  ulcer,  which  has  become  ad- 
herent to  them  and  perforated  over  them.  In  the  latter  case  the 
head  of  the  pancreas  and  the  left  lobe  of  the  liver  are  specially  in- 


*  The  patient  again  presented  himself  on  Xovember  1st,  and  had  then  46  per 
cent  acidity. 


DIAGNOSIS  OF  GASTRIC   ULCER.  259 

volved,  less  frequently  the  spleen.  There  is  also  a  lymphatic  gland 
in  the  ligainentum  gastrocolicum,  and  especially  a  chain  of  glands 
situated  near  by,  which  under  certain  circumstances  become  sympa- 
thetically swollen  and  sensitive  on  pressure,  and  which  may  be  de- 
tected on  palpation  as  small  tumors  of  the  size  of  a  hazel-nut  at  the 
lower  edge  of  the  stomach.  These  have  repeatedly  caused  me  great 
trouble  in  diagnosis.  In  all  these  cases,  the  fact  that  the  tumor  re- 
mains unaltered,  the  maintenance  of  strength,  and  the  presence  of 
hydrochloric  acid,  speak  for  the  diagnosis  of  ulcer  and  against  can- 
cer. Further,  as  may  be  assumed  from  what  I  have  already  told 
you  concerning  the  duration  of  these  processes,  a  course  lasting 
more  than  three  years,  and  the  absence  of  typical  cancerous  cachex- 
ia, point  toward  the  presence  of  the  former  affection. 

While  discussing  cancer  of  the  stomach  I  have  already  spoken 
of  the  transformation  of  an  ulcer  into  a  cancer.  Inasmuch  as  we 
know  that  h.yperacidity  is  the  rule  in  the  majority  of  cases  of  gas- 
tric ulcer,  we  ought  not  to  be  surprised  to  find  a  persistence  of  the 
secretion  of  hydrochloric  acid,  sometimes  even  up  to  the  normal 
amount,  in  certain  cases  of  cancer  which  have  developed  in  this 
way.  It  is  therefore  of  importance  from  a  diagnostic  standpoint 
to  consider  tumors,  especially  those  situated  at  the  pylorus,  Avhich 
are  accompanied  by  the  typical  symptoms  of  the  cancerous  cachexia, 
but  in  which  hydrochloric  acid  is  present  in  abundance,  as  being 
cancers  which  have  developed  from  ulcers.  I  have  repeatedly  seen 
such  cases.  In  one  of  them  a  tumor  at  the  pylorus  reached  the  size 
of  an  apple  within  a  year.  At  first  the  patient  presented  only  the 
symptoms  of  an  ulcer  with  hyperacidity  of  104  per  cent ;  this  hy- 
peracidity persisted  in  spite  of  the  development  of  the  tumor  and 
the  presence  of  well-marked  signs  of  stenosis.  Gastro-enterostomy 
was  performed  ;  at  the  operation  inspection  of  the  tumor  showed 
that  it  was  undoubtedly  a  cancer.  The  patient,  a  man,  twenty-seven 
years  of  age,  is  now  [January,  1892]  in  good  condition,  although 
the  tumor  has  reached  the  size  of  a  fist.  Dietrich  *  has  estimated 
the  frequency  of  such  cancers  to  be  5  per  cent  of  all  gastric  carci- 
nomas ;  Rosenheim  f  places  it  even  higher,  8  per  cent. 


Log.  cii.  \  Berl.  klin.  Wochensehr.,  1889,  No.  47. 

17 


2C0  DISEASES  OF  THE  STOMACH. 

After  all  tliat  has  been  said,  the  important  question  must  pre- 
sent itself  to  you,  whether  it  is  really  justifiable  and  necessary  to 
introduce  the  stomach-tube  in  cases  of  gastric  ulcer,  a  question  upon 
the  answer  to  which  most  important  results  may  at  times  depend. 
You  know  that  only  a  short  time  ago  this  was  always  answered 
with  a  decided  negative,  and  that  some  clinicians,  Leube  for  in- 
stance, even  yet  take  this  wise  precaution,  but  that  very  recently 
we  have  become  less  anxious  in  the  use  of  the  tube.  It  can  not  be 
denied  tliat  the  danger  of  causing  damage  in  introducing  the  soft 
tube  is  much  lessened  after  previously  cocainizing  the  throat ;  but 
it  is  not  entirely  eliminated.  x\nd  if  you  reflect  how  easy  it  is, 
even  in  practiced  patients,  for  movements  of  gagging  or  of  vomit- 
ing to  occur  in  the  course  of  the  manipulations,  and  if  you  will 
recall  Faber's  and  my  own  cases  cited  above,  you  will  agree  M^th 
me  that  examination  by  means  of  the  tube  must  be  undertaken  with 
the  greatest  caution,  and  that  it  should  only  be  used  in  those  doubt- 
ful cases  of  short  duration  in  which  no  hsematemisis  has  occurred, 
and  in  which  the  probability  of  a  deep  ulcer  is  slight.  So,  too, 
Germain  See,*  one  of  the  leading  clinicians  in  Paris,  rejects  lavage 
of  the  stomach  and  the  introduction  of  the  tube  in  cases  of  gastric 
ulcer,  and  cites  cases  of  Cornillon  and  Daguet,  in  which  lavage  was 
followed  by  fatal  haemorrhages.  For  the  sake  of  scientific  pur- 
poses we  may  risk  the  possible  dangers  in  the  clinic  or  in  a  hospital 
where  the  necessary  means  are  at  hand  in  case  of  emergency ;  but 
in  private  practice  and  in  dispensary  work  I  must  caution  against 
it  most  decidedly,  otherwise  I  fear  one  may  at  some  time  find  him- 
self in  an  exceedingly  uncomfortable  position.  It  may  happen  to 
any  one  of  us  that  in  introducing  the  tube  we  may  cause  haemor- 
rhage, and  we  may  even  be  so  unfortunate  as  to  cause  the  perfora- 
tion of  an  unsuspected  ulcer,  or  of  one  giving  but  vague  symptoms. 
This  might  easily  have  happened  to  me  in  the  case  reported  at  the 
commencement  of  this  lecture,  just  as  it  did  in  the  one  quoted  later 
on,  without  giving  rise  to  any  justifiable  reproach.  But  this  danger 
must  always  be  borne  in  mind.     It  is,  of  course,  greatly  lessened  by 


*  Gr.  See.    Hyperchlorhydrie  et  atonie  de  I'estomac.     Bull,  de  I'Acad.  de  med.,  1 
mai,  1888. 


DIAGNOSIS  OF  GASTRIC  ULCER.  261 

cocainizing  tlie  throat  before  introducing  tlie  tube  in  doubtful  cases, 
and  by  using  the  utmost  caution  in  aspirating  with  the  bulb  or  the 
stomach-pump  ;  it  is  equalized  and  more  than  equalized  by  the 
great  advantages  peculiar,  to  our  methods  of  examination.  But, 
nevertheless,  1  refrain  from  introducing  the  tube  in  all  cases  of 
ulcer  in  which  the  diagnosis  can  he  made  in  another  way ;  and  I 
desist  so  much  the  more,  since  in  these  cases  the  examination  of  the 
stomach-contents  does  not  establish  the  diagnosis^  and  since  it  does 
not  aid  us  in  the  treatment.  On  the  other  hand,  I  have  frequently 
observed  that  severe  haemorrhages  which  could  not  be  controlled  in 
any  otlier  way  have  been  checked  by  repeated  washing  out  of  the 
stomach  with  ice-cold  water. 

Among  the  facts  necessary  to  establish  the  diagnosis,  the  recog- 
nition of  h^ematemesis  or  of  melgena  may  present  some  difficulty,  to 
which  I  have  already  referred  {vide  page  247  et  seq.).  Let  me  here 
mention  an  apparently  secondary  matter,  but  which  to-day  plays  an 
important  role  in  the  examination  of  the  alvine  discharges.  I  refer 
to  the  use  of  water-closets.  Many  patients,  unless  confined  to  bed, 
are  unable  to  describe  their  dejecta,  beyond  speaking  of  the  vague 
impression  that  they  are  formed  or  otherwise,  or  that  the  quantity 
is  large  or  normal  or  small,  because  they  never  see  their  stools. 
Therefore  we  can  never  be  positive  of  a  possible  bloody  evacuation, 
as  well  as  of  many  other  facts.  A  striking  example  of  this  is  the 
following  case  quoted  from  my  case-book  : 

A  man,  thirty -eight  years  old,  had  suffered  for  five  years  with  stomach 
disturbances  which  at  first  manifested  themselves  only  in  a  feeling  of  full- 
ness in  the  stomach  after  eating,  occasional  belching,  and  constipation. 
Strict  diet  and  medication,  together  with  the  use  of  Carlsbad  (Mlihlbrun- 
nen)  water,  only  gave  slight  relief.  True  cardialgia  never  present.  One 
day,  a  year  ago,  he  had  abdominal  pains  and  diarrhoea  while  at  his  office, 
necessitating  his  using  the  closet  several  times  during  the  day.  Toward 
evening  he  suddenly  fainted,  and  was  carried  home  half  dead.  He  re- 
mained in  bed  five  weeks,  and  recovered  slowly.  Was  quite  well  the  fol- 
lowing summer,  complaining  only  of  slight  gastric  oppression.  Now,  for 
about  eight  weeks,  he  has  had  great  difficulty,  especially  marked  regurgi- 
tation and  repeated  vomiting  some  time  after  eating,  chiefly  during  the 
night  between  ten  and  twelve  and  two  and  three  o'clock.  Relief  after 
vomiting.  He  claims  that  there  never  was  any  blood  in  the  vomit  or 
faeces.     Constipated.     Feeling  of  fatigue  marked. 

With  the  exception  of  slight  sensitiveness  on  pressure  nothing  could 


262  DISEASES  OP  THE  STOMACH. 

be  discovered  either  in  the  epigastrium,  or  to  the  right  of  this  in  the  para- 
sternal line  under  the  free  border  of  the  ribs.  The  acidity  after  the  test- 
breakfast  was  84— i.  e.,  hyperacidity  was  present. 

There  can  be  no  doubt  that  this  is  a  case  of  gastric  or  duodenal 
ulcer,  and  that  the  apparent  "  diarrhoea  "  was  the  resulting  profuse 
hsemorrhage  leading  to  fainting,  while  the  other  conditions  causing 
haemorrhage  from  the  bowels,  such  as  tuberculosis,  ulcers,  diseases 
of  the  portal  vein  and  of  the  liver,  etc.,  can  be  excluded.  Later  on 
the  patient  remembered  that  he  had  seen  blood  on  the  closet-paper. 
How  often,  however,  may  such  hsemorrhages  occur  without  coming 
to  the  knowledge  of  the  patient  or  of  the  physician !  Only  a  short 
time  ago  I  had  another  case  of  this  kind  in  which  a  man,  suffering 
with  gastralgia,  after  a  short  sojourn  in  Carlsbad,  had  two  severe 
attacks  of  syncope,  which,  now  that  symptoms  of  a  duodenal  ulcer 
have  become  more  plainly  developed,  can  only  be  referred  to  severe 
internal  intestinal  haemorrhage. 

Considerable  difficulty  may  arise  in  making  a  differential  diag- 
nosis between  liejpatiG  colic  and  gastralgia  due  to  an  ulcer  at  the  pylo- 
rus or  in  the  duodenum.  ISTaturally,  not  in  the  typical  cases  of  either 
disease !  Just  as  positively  as  the  complete  list  of  symptoms  given 
above  shows  the  presence  of  an  ulcer,  we  may  establish  a  diagnosis 
of  hepatic  colic  if  we  find  constantly  recurring  pain  in  the  right 
hypochondrium  independent  of  the  ingestion  of  food,  possibly  mild 
febrile  movements,  jaundice,  swelling  of  and  pain  over  the  liver, 
together  witli  a  gall-bladder  which  may  be  palpated,  possibly  with 
gall-stones,  and  the  presence  of  the  latter  in  the  stool.  But  very 
many  cases  occur  in  which  the  symptoms  are  so  shifted  about  that 
we  can  scarcely  avoid  mistaking  one  for  the  other.  If  in  cases  of 
hepatic  colic  jaundice  may  frequently  be  absent  or  very  slight,  so, 
on  the  other  hand,  we  not  uncommonly  find  cases  of  gastralgia  with 
slight  icterus,  due  perhaps  to  the  convulsive  contraction  of  the  ab- 
dominal viscera  forcing  the  bile  into  the  blood,  or  perhaps  because 
a  very  transient  sympathetic  spasm  of  the  hepatic  duet  has  caused  a 
stagnation  of  the  bile.  Frequently,  too,  the  patients  refer  the  pain 
in  hepatic  colic  more  toward  the  mid-line,  especially  the  case  in 
women,  in  whom  lacing  has  altered  the  topography  of  the  liver. 
Should  the  pylorus  be  displaced  somewhat  toward  the   right,  or 


DIAGNOSIS  OF   GASTRIC  ULCER.  263 

should  tlie  ulcer  lie  in  tlie  horizontal  portion  of  the  duodenum,  a 
local  differentiation  would  be  wholly  out  of  the  question.  Thus  we 
may  remain  in  doubt  for  a  long  time,  or  indeed  never  decide  whether 
we  have  to  deal  with  hepatic  colic  or  with  gastralgia.  Here,  again, 
the  presence  of  hyperacidity  of  the  gastric  contents  offers  us  a  val- 
uable diagnostic  aid.  Results  in  which  the  acidity  amounts  to  more 
than  80 — i.  e.,  0*3  per  cent  of  hydrochloric  acid — -may  be  regarded 
as  denoting  this. 

ISTot  only  is  the  diagnosis  of  the  existence  of  an  ulcer  to  be 
established,  but  its  site  as  well.  This  assertion  has  frequently  been 
made,  only  lately  even  by  Gerliardt.  Can  this  be  done  ?  Accord- 
ing to  my  conviction  and  experience,  it  is  only  in  those  cases  in 
which  the  circumstances  are  unusually  favorable,  that  an  ulcer  sit- 
uated at  the  pylorus  or  in  the  duodenum,  or  perhaps  on  the  greater 
curvature,  may  be  made  out.  On  the  other  hand,  ]3roceeding  by 
exclusion,  we  may  surmise  that  the  site  of  the  ulcer  is  elsewhere. 
In  contrast  to  this,  ulcer  of  the  pylorus  can  be  recognized  by  a 
sharply  localized  pain  a  little  to  the  right  of  the  middle  line.  But 
the  element  of  time  as  a  factor  in  the  causation  of  the  pain  now 
leaves  us  in  the  lurch,  and  I  find  the  assertion  that  ulcers  in  the 
cardiac  portion  of  the  stomach  are  accompanied  by  pain  imme- 
diately after  eating,  while  those  at  the  pylorus  only  cause  pain  later, 
to  be  neither  sufficiently  proved  clinically  nor  warranted  under  the 
circumstances.  We  really  can  not  conceive,  or  at  least  we  have  no 
grounds  for  so  doing,  that  the  ingesta  are  retained  at  the  cardia  and 
only  reach  the  pylorus  after  an  appreciable  interval.  Attempts 
have  also  been  made  to  locate  the  site  of  the  ulcer  by  the  position 
which  some  patients  assume  in  order  to  ease  the  j)ain.  If  the  j^ain 
is  lessened  when  the  patient  lies  on  the  left  side,  the  ulcer  is  said  to 
be  situated  on  the  lesser  curvature,  and  vice  versa.  This,  too,  may 
be  considered  a  doubtful  and  unreliable  symptom— the  more  so,  since 
the  majority  of  patients  have  no  such  experience.  If  the  site  of 
the  ulcer  in  the  stomach  were  discovered,  it  would  perhaps  be  of 
practical  significance  in  predicting  the  possible  resulting  conditions. 
According  to  Gerhardt,*  "  sensitiveness  on  pressure  and  a  tumor " 

*  Loc.  cii. 


264  DISEASES  OF  THE  STOMACH. 

point  "  more  toward  the  site  being  on  the  anterior  wall,  pain  in  the 
back  and  haemorrhage  more  to  its  being  on  the  posterior  wall.  Ul- 
cers in  the  regions  of  the  fundus  or  the  pylorus  may  often  be  dis- 
tinguished bj  the  location  of  the  pain  and  by  its  increase  in  the 
lateral  posture.  Ulcer  of  the  fundus  adherent  to  the  spleen  may 
lead  to  chills,  owing  to  splenitis,  as  I  (Gerhardt)  have  seen  in  three 
cases."  It  need  not  be  specially  mentioned  that  dilatation  of  the 
stomach  points  to  the  site  of  the  ulcer  being  at  the  pylorus  or  in 
the  duodenum,  and  that  contraction  shows  that  it  is'  at  the  cardia. 
However,  if  you  consider  how  vague  a  symptom  sensitiveness  on 
pressure  is ;  how  rare  the  occurrence  of  a  tumor  caused  by  an  ulcer  is 
in  comparison  with  the  total  number  of  cases ;  how  little  we  are  able 
to  establish  the  condition  of  contraction  during  life ;  and  if  you  will 
recall  the  case  of  perforation  of  a  necrotic  carcinoma  of  the  lesser 
curvature  accompanied  by  chills,  cited  on  page  181 ;  and,  finally,  if 
you  know  that  frequently  numerous  ulcers  are  situated  in  different 
places — you  will  be  able  to  appreciate  the  unreliability  of  these  signs. 
I  can  not  agree  with  this  statement  of  Gerhardt,  "  If  the  diagnosis 
is  to  be  positive  it  must  also  indicate  the  site  of  the  ulcer  "  ;  in  most 
cases  I  am  content  and  well  satisfied  if  I  can  feel  sure  of  the  diag- 
nosis of  ulcer,  at  times  so  difficult  to  be  made. 

All  that  has  been  said  concerning  the  site  of  the  ulcer  in  the 
stomach  refers  also  to  its  position  in  the  duodenum.  In  at  least  90 
per  cent  of  the  cases  it  is  impossible  to  decide  positively  whether 
we  are  dealing  with  a  gastric  or  a  duodenal  ulcer.  For  the  duode- 
num, and  especially  its  horizontal  portion,  may  for  this  purpose  be 
really  regarded  as  only  a  continuation  or  a  portion  of  the  stomach ; 
and  the  ulcerative  process  is  accompanied  by  the  same  phenomena 
in  this  case  as  it  is  in  the  other.  Those  factors  which  indicate  an 
ulcer  at  the  pylorus  also  speak  for  the  duodenal  ulcer,  and  the  more 
so  since  the  latter  at  times  extends  directly  from  the  pylorus  into 
the  duodenum.  A  duodenal  ulcer  is  probably  present  if  the  pain 
does  not  develop  until  some  time  after  the  ingestion  of  food,  if  the 
position,  together  with  sensitiveness  on  pressure,  is  situated  decid- 
edly to  the  right  of  the  parasternal  line,  and  if  possibly  there  are 
profuse  bloody  stools  without  any  hsemateraesis.  The  fact  that  duo- 
denal  ulcers   often    appear  after   extensive  cutaneous    burns  may 


PROGNOSIS  OF  GASTRIC  ULCER.  265 

in  sucli  cases  be  of  service  in  diagnosis.  A  point  of  support,  but  no 
more,  is  offered  by  the  rarer  occurrence  of  ulcer  of  the  duodenum. 
Tlius  Willigk  reports  only  6  duodenal  ulcers  to  225  in  the  stomach, 
and  Trier  places  the  figures  at  28  to  261.  Yet  even  in  this  small 
percentage  a  number  of  cases  are  included  in  which  ulcers  existed  in 
the  stomach  and  duodenum  at  the  same  time.  Gastralgia  is  said 
to  be  less  common  because,  as  Budd  believes,  the  duodenum  is 
not  subjected  to  as  much  traction  and  change  of  position  as  the 
stomach.  Moreover,  the  very  uncommon  appearance  of  jaundice  can 
be  of  no  more  aid  in  diagnosis  than  the  circumstance  that,  on  the 
whole,  intestinal  hcemorrhages  are  more  frequent  here  than  htema- 
temesis,  for  we  find  that  ulcer  of  the  stomach  also  leads  to  the  for- 
mer, and  that  duodenal  ulcer  is  also  accompanied  by  the  latter. 

Prognosis. — Till  within  a  short  time  it  was  customary  and  proper 
to  give  a  doubtful  prognosis  in  cases  of  gastric  ulcer,  when  the  diag- 
nosis could  only  be  made  by  the  established  symptoms.  But  now, 
since  we  are  able  to  recognize  its  early  stages,  and  to  differentiate  it 
from  other  dyspepsias,  since  the  principles  of  treatment  have  be- 
come apparent  to  us,  and  we  are  in  the  position  to  apply  them  at 
the  commencement  of  the  process,  the  prognosis  has  become  essen- 
tially better  so  far  as  the  early  stages  of  the  ulcer  are  concerned. 
We  may  now,  if  the  patients  subject  themselves  to  a  rational  course 
of  treatment — i.  e.,  the  rest-cure — at  the  proper  time,  give  them 
well-grounded  prospects  of  recovery  ;  and  even  in  cases  of  classical 
ulcer  we  may  hope  for  cure  or  for  decided  improvement.  It  is  to 
be  regretted  that  during  the  earliest  stages,  which  are  not  very 
troublesome  subjectively,  very  few  patients  are  either  willing  or  in 
the  position  to  subject  themselves  to  a  course  of  treatment  which  is 
always  exacting.  However,  if  we  succeed  in  permanently  remedy- 
ing the  anomalies  in  the  composition  of  the  blood  or  the  secretion 
of  gastric  juice,  we  lessen  the  danger  of  relapses,  which  otherwise 
always  threaten  us,  and  only  too  often  appear.  But  the  conse- 
quences of  traction  by  the  cicatrices,  especially  after  the  healing  of 
extensive  ulcers,  always  remain  to  be  feared,  as  well  as  the  accom- 
panying permanent  impairment  of  the  general  health  which  can  not 
be  remedied.  In  such  cases,  therefore,  the  prognosis  must  always 
be  made  with  great  care.     But  that  it  is  nevertheless  not  a  poor  one 


266  DISEASES  OP  THE  STOMACH. 

can  be  deduced  from  the  well-known  fact  that  the  scars  of  gastric 
ulcers  are  found  about  twice  as  often  as  the  ulcers  themselves.  In 
haemorrhage,  if  this  is  not  immediately  fatal,  the  prognosis  is  on 
the  whole  favorable.  As  a  rule  we  are  able  to  control  the  bleed- 
ing bj  means  of  appropriate  treatment,  and  even  to  remedy  ex- 
treme ansemia  in  a  relatively  short  time.* 

Treatment.— I  know  but  one  form  of  treatment  which  holds  out 
prospects  of  success,  and  which,  if  applied  in  the  early  stages,  can 
show  any  favorable  results.  This  is  the  rest-cure  introduced  into 
Germany  by  von  Ziemssen  f  and  Leube, :{:  by  which  the  stomach 
is  protected  from  all  irritating  factors,  as  a  broken  bone  is  immo- 
bilized in  plaster,  with  of  course  the  difference,  that,  while  this  is 
absolute  in  the  latter  instance,  it  can  only  be  approximately  attained 
in  the  former.  The  principle  of  this  treatment,  long  since  recom- 
mended in  England  by  Wilson  Fox  and  Balthazar  Forster,*  consists 
of  rest  in  bed  and  rectal  alimentation,  with  such  nourishment  as  will 
cause  the  stomach  the  least  trouble.  As  adjuvants  we  have  moist 
heat  in  the  form  of  external  applications,  which  quiet  the  pain  [ex- 
cept when  there  is  bleeding]  and  at  the  same  time  diminish  the  irri- 
tation ;  and,  internally,  in  the  form  of  a  Trinkcur,  hot  Carlsbad 
water  or  a  solution  of  Carlsbad  salts. 

I  could  quote  a  large  number  of  cases  either  cured  with  sur- 
prising rapidity  and  safety  by  this  method,  or  at  least  freed  for  a 
long  time  from  all  difficulties,  but  the  following  will  suffice  : 

In  October,  1888,  I  was  called  in  consultation  to  see  Mrs.  Tr.,  aged 
thirty-seven,  a  widow  who  supported  her  children  by  working  on  the  ma- 
chine as  seamstress.  Typical  history  of  ulcer,  haematemesis,  gastralgia. 
Severe  pain  after  each  meal,  and  also  at  times  during  the  night  and 
morning  on  an  empty  stomach.  Dieted  strictly  and  lost  much  flesh. 
Appeared  pale  and  miserable.  Pain  on  pressure  in  the  epigastrium.  No 
tumor.  Abdominal  walls  soft,  strong  muscular  contraction  occui'ring 
only  on  making  pressure  at  the  spot  mentioned.  No  wandering  kidney. 
Urine  negative. 


*  [Oser  claims  that  in  straightforwa;rd  cases  the  prognosis  is  better  than  in 
chronic  catarrhal  gastritis. — Tr.] 

f  Ziemssen.    Ueber  die  Behandlung  des  Magengeschwiirs.   Volkmann's  Samml., 
klin.  Vortrage,  No.  15. 

X  Leube.     Magenkrankheiten,  S.  117. 

*  Loe.  cit.,  p.  344. 


TREATMENT  OP  GASTRIC   ULCER.  267 

Patient  treated  till  the  middle  of  January,  1889,  with  internal  medica- 
tion—nitrate of  silver,  bismuth  with  ext.  hyoscyam.  and  morphine,  tinct. 
opii,  etc. — but  without  success.  At  last,  on  January  14th,  she  applied  for 
admittance  at  the  Augusta  Hospital.  The  typical  ulcer-cure  was  insti- 
tuted, and  the  patient  was  treated  in  the  manner  soon  to  be  described. 
Her  troubles  were  rapidly  lessened,  and  then  ceased  entirely.  The  sensi- 
tiveness at  the  pit  of  the  stomach — a  point  on  which  I  always  lay  great 
stress — disappeared,  and  on  the  20th  of  February,  that  is,  after  six  weeks, 
the  patient  was  discharged  cured.  Inasmuch  as  she  was  very  foolish 
regarding  her  diet,  and  during  her  convalescence  took  more  than  was 
allowed  her,  aud  as  this  propensity  was  responsible  for  a  renewed  attack 
of  gastralgia  at  about  the  middle  of  the  treatment,  we  can  really  say  that 
she  gave  us  still  stronger  proof  of  her  recovery.  She  has  also  remained 
free  from  relfipses  up  to  the  present  time. 

However,  I  dare  not  conceal  the  fact  that  such  a  jDrompt  cure 
does  not  always  result,  and  that  I  have  also  had  cases  which  as  long 
as  they  were  taking  the  "  cure  "  felt  very  well,  but  as  soon  as  they 
returned  to  their  daily  life,  even  if  with  all  precautions,  suffered 
from  fresh  attacks  and  the  return  of  the  old  difficulties,  l^everthe- 
less,  these  have  always  been  in  the  minority. 

Leube  emphasizes  the  fact  that  the  composition  of  the  Carlsbad 
salt  is  both  neutralizing  and,  owing  to  the  sodium  chloride  which 
it  contains,  stimulating  in  its  action  ;  but  as  we  know  that  the  acid- 
ity is  increased  in  the  majority  of  cases,  the  latter  property  may 
be  regarded  more  as  a  disadvantage.  Depression  rather  than  stimu- 
lation is  indicated.  ISTeither  can  I  ascribe  very  much  importance  to 
the  neutralization  or  diminution  of  the  acidity  if  this  be  done  but 
once,  and  then  in  a  stomach  containing  no  food,  which,  unless  there 
is  continuous  secretion  (hypersecretion),  is  therefore  empty.  The 
essential  indications  seem  rather  to  be  the  reduction  of  the  hyper- 
secretion by  means  of  neutral  salts,  as  already  surmised  by  Pember- 
ton,  and  directly  proved  by  Jaworski,*  and  in  the  sedative  action 
of  large  quantities  of  warm  water ;  f  and,  finally,  in  the  laxative 
effects  of  the  neutral  salts.  If  the  action  of  the  waters  of  the 
simple  alkaline  springs  has  been  found  to  be  less  effective  than  that 

*  Jaworski.  Ueber  Wirkung,  therapeutiseher  Werthe  und  Gebraueh  des  neuen 
Carlsbader  Quellsalzes.     Wiener  med.  Wochenschr.,  6-16,  1886. 

f  [Oser  cautions  against  giving  too  large  amounts  of  water  or  anything  producing 
large  quantities  of  gas,  on  account  of  the  danger  of  distending  the  walls  of  the 
stomach,  and  thus  opening  the  ulcer.  However,  this  seems  to  be  theoretical  rather 
than  practical. — Tk.] 


268  DISEASES   OF  THE  STOMACH. 

of  the  alkaline  saline,  it  is  probably  due  to  the  failure  of  supplying 
the  laxative  effects  by  other  means. 

Where  this  laxative  action  is  absent,  as  is  frequently  the  case  in 
the  Carlsbad  waters,  we  must  produce  it  by  the  addition  of  Glau- 
ber's salt,  or  better  by  means  of  vegetable  cathartics,  preferably 
rhubarb  or  senna  in  watery  infusion.  Moreover,  it  is  not  necessary 
for  us  to  adliere  too  narrow-mindedly  to  one  standard ;  our  watch- 
word is  necessity.  It  is  immaterial  whether  we  relieve  the  pain  by 
hot  fomentations,  or,  if  these  be  ineffectual,  by  subcutaneous  injec- 
tions of  mor23hine ;  whether  we  give  the  patient  a  solution  of  Spru- 
del  salt  or  the  natural  Carlsbad  spring-water,  or  that  of  an  effer- 
vescing soda  spring,  such  as  Ems,  or  Vichy,  or  ISTeuenahr,  and  sup- 
ply the  laxative  action  missing  in  these  waters  by  means  of  other 
aperients.  "We  give  300  to  500  c.  c.  [f  §  x  to  Oj]  of  Carlsbad  water. 
It  is  immaterial  from  which  spring  it  comes,  because  there  are 
no  essential  differences  in  their  chemical  composition,  while 
the  differences  of  temperature  existing  in  the  waters  of  the  indi- 
vidual hot  springs  may  be  disregarded,  for  they  are  always  taken 
only  as .  hot  as  the  patient  can  bear  them ;  in  other  words,  at  about 
the  same  temperature.  Of  the  salt  about  15  grammes  [one  table- 
spoonful]  are  dissolved  in  one  half  litre  [one  pint]  of  [hot]  water. 
This  is  taken  as  at  the  "  cure " — i.  e.,  small  swallows  at  j)roper 
intervals. 

For  the  first  three  days  I  give  the  patients  absolutely  no  food, 
and  allow  them  only  a  nutritive  enema  three  times  daily.  Then 
feeding  by  the  mouth  is  commenced  with  small  quantities  of 
milk-*  and  flour-soups ;  later  on  I  give  leguminous  soups,  then 
leguminous  vegetables  and  potatoes  in  the  form  of  a  puree,  to 
which  small  quantities  of  meat-broth  are  added  later.  Only 
in  the  third  week  is  a  quantitatively  and  qualitatively  ampler 
diet  permitted,  but  always  with  the  view  of  sparing  the  stomach 
as  much  as  possible.  We  must  of  course  individualize,  for  the 
patients  undoubtedly  lose  flesh  on  this  diet.  But  they  recover 
rapidly,   the    gastralgic    attacks   remain   absent,    and    now  is   the 

*  Cruveilhier  was  the  first  to  recommend  the  milk  diet.  Flour-soups  cooked 
with  milk  are  preferable  to  pure  milk,  because  the  casein  coagulates  more  floceu- 
lently  than  it  does  in  pure  milk. 


TREATMENT  OP  GASTEIC  ULCER.  269 

time  to  meet  the  second  indication,  to  improve  the  general  con- 
dition.* 

For  this  purpose  we  use  the  iron  preparations,  eitlier  alone  or  in 
combination  with  arsenic.  The  former  are  indicated  in  cases  of 
pure  chlorosis  or  anaemia,  the  latter  if  we  have  to  deal  with  an  en- 
feebled nervous  system  and  we  wish  to  exert  an  indirect  action 
upon  it  bj  direct  stimulation  of  metabolism.  The  scruples  formerly 
existing  against  the  use  of  iron  in  cases  of  gastric  ulcer  were  caused 
by  the  experience  that  this  drug  is  often  poorly  borne  as  long  as  an 
active  process  is  going  on ;  but  they  are  not  justified  as  soon  as 
recovery  has  commenced  and  is  well  under  way.  I  can  at  least 
fully  concur  in  the  experiences  which  Te  Gemptf  has  published  on 
this  subject.  He  uses  Drees's  liquor  ferri  albumin.,  which,  as  is 
well  known,  is  a  preparation  made  by  treating  albumen  with  chlo- 
ride of  iron,  and  which  is  very  expensive.:]:  Inasmuch  as  all  we 
care  for  is  to  introduce  the  proper  proportions  of  albumen  and  iron 
into  the  stomach,  so  as  to  produce  an  absorbable  peptonate  of  iron, 
and  inasmuch  as  we  know  that  the  power  of  forming  peptones  is 
not  extinguished  in  ulcer  of  the  stomach,  I  prescribe  this  medica- 
ment in  a  simpler  and  less  expensive  manner.  I  order  thi-ee  times 
daily  a  teaspoonful  of  a  2  to  3  per  cent  solution  of  ferri  sesqui- 
chlor.  (Ph.  Ger.)  [ferri  chloridum,  U.  S.  P.]  to  be  added  to  a  wine- 
glassful  of  egg-water  (one  part  of  white  of  egg  to  two  parts  of 
water)  and  taken  through  a  glass  tube  in  order  to  spare  the  teeth. 
The  advantages  of  the  chloride  of  iron,  as  one  of  the  mildest  and 
most  easily  assimilable  preparations  of  iron,  have  been  extolled  by 
many ;  with  these  I  also  wish  to  join.  However,  it  is  well  kno-WTi 
that  every  one  has  a  favorite  iron  preparation,  and  if  you  have 
more  confidence  in  any  other  and  get  good  results  with  it,  do  not 
discontinue  its  use ;  for  success  does  not  depend  upon  the  prepara- 


*  [Da  Costa  reports  three  cases  of  gastric  ulcer  which  he  treated  successfully  -with 
ice-cream  ad  libitum.  The  ice-cream  must  contain  no  corn-starch  or  other  sub- 
stances employed  for  thickening  purposes,  and  it  must  not  be  over  twenty-four 
hours  old.     Medical  News  (Philadelphia),  August  8.  1891  p.  155. — Tr.] 

f  Te  Gempt.  Ueber  Behandlung  des  mnden  Magengesehwlirs  mit  Eisenalbu- 
minat.    Berl.  klin.  Wochenschr.,  1886,  S.  240. 

X  [Dietterieh's  peptonate  of  iron  and  Pizalla's  albuminate  of  iron  are  more  com- 
mon in  this  country. — Tr.] 


270  DISEASES  OP  THE  STOMACH. 

tioii,  but  upon  its  assimilation,  and  especially  upon  its  action  on  tlie 
blood.  I  formerly  gave  arsenic  in  the  form  of  Fowler's  solution, 
together  witli  tinct.  ferri  clilor.  According  to  Liebreicli's  brilliant 
investigations,  arsenious  acid  appears  to  be  more  effective,  and  I 
prescribe  it  in  pills  containing  2  milligrammes  [gr.  -gJ^]  of  arsenious 
acid  and  2  centigrammes  [gr.  |-]  of  ferri  sesquiclilor.  [Ph.  Ger.].  It 
is  advisable  to  employ  increasing  doses,  and  to  give  the  drugs  after 
meals.  This  regimen  must  be  continued  for  months,  during  which 
the  use  of  arsenic  is  to  be  discontinued  for  three  to  five  days  every 
three  weeks.  The  combined  use  of  arsenic  and  iron  may  thus  be  con- 
tinued for  a  long  time,  if  we  employ  the  caution  of  giving  the  arsenic 
in  increasing  and  then  diminishing  doses,  say  from  3  to  10  pills !  a  day. 
The  diet  may  gradually  become  more  generous,  but  must  neverthe- 
less be  strictly  regulated  for  months;  and  those  patients  who 
tend  to  excesses  must  be  made  to  adhere  rigidly  to  a  written  bill 
of  fare  and  a  certain  allowance  of  food. 

This  treatment  brilliantly  confirms  the  remark  of  Leube,  that 
"  the  treatment  of  gastric  ulcer  remains  a  thankful  task  to  the  phy- 
sician because  the  cures  form  by  far  the  greater  majority  of  the 
therapeutic  results,  if  we  include  those  cases  in  which  the  patients 
are  freed  from  all  difficulties  for  a  long  time,  and  have  relapses  only 
later  on  "  ;  *  and  also,  "  I  am  convinced  that  the  more  strictly  the 
dietetic  directions  are  carried  out  at  the  bedside,  the  more  will  the 
unpleasant  medicinal  treatment  of  ulcer  of  the  stomach   dwindle 


However,  the  latter  is  nevertheless  indispensable :  first,  because 
there  are  very  many  patients  who  are  unwilling  or  unable  to  sub- 
ject themselves  to  such  a  "  cure  "  ;  secondly,  because  there  are  many 
cases  which  present  urgent  symptomatic  indications  which  must  be 
met  immediately. 

Bismuth  has  enjoyed  a  very  great  reputation  ever  since  it  was 
first  recommended  by  Odier,  of  Geneva,  although  we  have  never 
been  sure  of  its  mode  of  action,  as  is  shown  by  the  great  variations 
in  its  dosage,  from  0*1  gramme  [gr.  jss.]  up  to  15  grammes  [  f  ss.]. 
Given  by  Odier  ^^  enterieurement  comme  antispasmodique,''''  it  was 

*  Leube.     Magenkrankheiten,  S.  113. 


TREATMENT  OF  GASTRIC   ULCER.  271 

used  later,  for  instance  bj  the  English  school,  for  the  purpose  of 
remedying  an  "  undue  secretion."  In  our  day  the  remarkable  sup- 
position is  frequently  advanced  that  the  comparatively  diminutive 
amount  of  the  preparation  introduced  into  the  stomach  selects  the 
surface  of  the  ulcer  on  which  to  deposit  itself  and  form  a  protective 
covering.  Since  we  give  it  chiefly  in  doses  of  0"5  gramme  [gr.  vijss.] 
together  with  5  to  10  milligrammes  [gr,  J^-  to  ^']  of  morphine,  it 
can  not  be  said  how  much  of  the  jDOSsible  action  is  to  be  ascribed  to 
the  latter.  To  me  the  French  method  appears  to  be  the  most  ra- 
tional, in  which  large  doses,  10  to  15  grammes  [  3  ijss.  to  §  ss.],  are 
given  susj)ended  in  water.  However,  on  account  of  the  expense, 
this  is  a  line  of  treatment  not  applicable  to  all. 

But  bismuth  has  been  given  with  "  success  "  by  so  many  excel- 
lent practitioners,  especially  in  cases  of  gastralgia — Budd  recom- 
mends it  just  ''  in  gastralgia  with  increased  secretion  of  the  gastric 
acid  " — that  all  possibilities  of  illusion  seem  to  be  excluded.  ISTev- 
ertheless,  the  question  whether  it  possesses  a  speciiic  action,  or 
whether  it  can  not  be  just  as  well  replaced  by  some  other  prepara- 
tion of  a  poorly  soluble  alkaline  salt — e.  g.,  bicarbonate  of  calcium — 
must  still  remain  undecided. 

What  I  have  said  of  bismuth  will  almost  apply  to  nitrate  of 
silver.  Here,  too,  we  are  entirely  in  the  dark  as  to  its  mode  of 
action,  for,  as  Leube  has  said,  we  can  scarcely  believe  in  a  direct 
local  action  of  the  small  doses — 0"01  gramme  [gr.  •!-] — of  nitrate  of 
silver,  and  it  is  no  more  possible  that  any  effective  combination  with 
an  acid  can  be  formed  by  it.  ITotwithstanding  this,  we  also  have 
weighty  evidence  (I  will  only  mention  Gerhardt)  in  favor  of  the 
effectiveness  of  the  drug.  In  a  few  cases  I  have  obtained  decided 
but  also  only  transient  relief  of  the  difficulties  with  a  solution  of 
0'2  [gr.  iij]  argent,  nitrat.  in  150  [f  5"^"]  oi  water,  taken  every  two 
hours ;  while  in  other  cases  I  had  to  discontinue  the  drug  after  it 
had  been  used  a  few  times,  because  increased  discomfort  in  the 
stomach,  nausea,  anorexia,  coated  tongue,  and  also  constipation  ap- 
peared. On  the  other  hand,  in  several  cases  under  my  care  I  had  to 
discard  it  because  just  the  reverse  occurred — namely,  watery  evacu- 
ations always  followed  almost  immediately  after  taking  it. 

In  my  opinion,  the  dietetic  principles  given  above  are  also  the 


2Y2  DISEASES  OF  THE  STOMACH, 

most  serviceable  in  the  treatment  of  ambulatory  cases,  and  we  must 
endeavor  to  carry  them  out,  at  least  as  far  as  the  diet  is  concerned, 
as  fully  as  possible.  Here  we  must  give  special  consideration 
to  milk,  the  neutralizing  action  of  Avliich  on  acids  is  well  known, 
and  which,  moreover,  has  only  lately  been  firmly  established  by  the 
experiments  of  Leo  and  von  Pfungen.  It  is  to  be  regretted  that  so 
many  show  a  repugnance  to  milk  in  all  forms,  and  no  matter  what 
may  be  added  to  it,  whether  soda  or  lime  water,  brandy  or  coffee, 
etc.  Frequently,  in  such  cases,  peptonized  milk,  made  pleasant  to 
the  taste  with  sweet  cream,  can  be  taken.  Moreover,  I  try  to  blunt 
the  hyperacid  gastric  juice  by  the  hourly  exhibition  of  small  doses 
of  an  alkali  combined  with  rhubarb  and  cane  or  milk  sugar.  The 
rhubarb  acts  mildly  on  the  bowels,  while  the  sugar  has  a  decided 
anodyne  action,  on  account  of  which  it  has  frequently  been  rec- 
ommended. I  have  seen  fairlj'-  good  results  from  the  following 
powder : 

^    Magnesiag  ustag, 
Sodii  carbonatis, 

Potass,  carbonatis aa  5*0     [  3  j  gr.  xv] 

Pulv.  rad.  rhei 10-0     [  3  ijss.] 

Sacch.  lactis 25'0    [  3  vj  gr.  xv] 

•     M.     Sig. :  A  large  pinch,  dry  on  the  tongue,  every  hour. 

Morphine,  either  by  the  mouth  or  subcutaneously,  stands  first 
for  the  relief  of  severe  gastralgia.  Solutions  of  chloroform  (1  :  120, 
5  ss.  every  two  hours)  have  at  times  an  excellent  effect,  not  only  on 
the  temporary  pain,  but  altogether  on  the  course  of  the  j^rocess. 
Among  the  remaining  anodynes  I  have  frequently  used  lupulin, 
ext.  cannabis  indie,  ext.  hyoscyam.,  and  belladonna  experimentally, 
but  I  have  always  been  obliged  to  return  to  morphine.  Formerly 
leeches  were  frequently  applied  over  the  affected  site ;  blisters  and 
even  the  cautery  were  used.  Ice-bags  will  suffice,  or  ice-cold  or 
warm  applications,  or  Leiter's  coil,  which,  where  circumstances 
allow  it,  is  the  cleanest  and  most  comfortable  way  of  applying 
cold. 

Toothing  is  more  serviceable  in  vomiting  than  a  carefully  regu- 
lated diet.  We  may  allow  the  patients  to  drink  large  quantities  of 
warm  water  several  times  during  the  day,  and  also  give  them  pieces 


TREATMENT  OP  GASTRIC   ULCER.  273 

of  ice  with  cLloroform.  But,  as  tlie  vomiting  usually  ceases  with 
the  gastralgia,  it  is  met  by  the  treatment  of  the  latter. 

Special  care  is  required  in  hcematemesis,  not  only,  as  is  self- 
evident,  when  it  is  profuse,  but  also  when  the  hoemorrhages  are 
smaller.  The  first  indication  under  all  circumstances  is  absolute 
physical  and  mental  rest,  and  the  avoidance  of  all  internal  and  ex- 
ternal irritation  to  the  stomach.  Even  in  the  smaller  heemor- 
rhages,  since  they  frequently  are  precursors  of  larger  ones,  the  pa- 
tients, if  circumstances  will  permit,  ought  to  subject  themselves  to 
this  regimen  for  several  days,  and  the  entire  plan  of  treatment 
should  be  carried  out.  We  may  give  small  pieces  of  ice,  or  table- 
spoonfuls  of  ice-cold  tea  or  ice-cold  fluid  peptone  solutions.  [For 
the  use  of  washing  out  of  the  stomach  with  ice-cold  water  in  other- 
wise uncontrollable  haemorrhage,  see  page  261.]  In  the  cases  in 
which  it  is  not  known  whether  the  patients  take  milk  well,  I  do 
not  give  it,  but  instead  I  prescribe  for  the  first  day  a  solution  of 
grape  sugar,  which  is  replaced  by  some  bouillon  made  of  meat- 
peptones  taken  very  cold,  or  cold  thin  gruels  made  of  barley  or  oat- 
meal. Where  it  is  possible,  I  order  nutritive  enemata,  which  must 
be  given  with  care.  Several  times  during  the  day  I  inject  one  or 
two  syringef uls  *  of  the  following  into  the  region  of  the  stomach  : 

^  Ext.  secalis  cornuti  [Ph.  Ger.] 2*5  [gr.  xxxvij] 

Glycerini, 

Aquae aa  5-0  [f  3  j  -ni  xv].    M. 

[See  page  212.]  However,  I  must  add  that  in  some  persons  ergo- 
tin  causes  very  unpleasant  symptoms  of  oppression  and  dizziness. 
In  case  the  patients  are  much  excited,  morphine  may  be  added 
to  this  injection.  As  a  rule,  the  haemorrhages,  unless  they  come 
from  too  large  a  vessel,  are  controlled  by  this.  Formerly,  rem- 
edies which  have  the  reputation  of  being  styptics,  like  acetate  of 
lead,  chloride  of  iron,  and  oil  of  turpentine,  were  given  internally ; 
but  we  do  not  use  them  now,  since  we  have  a  much  more  effective 
and  rational  remedy  in  ergot.  Bearing  in  mind  that  hydrastis 
canadensis  and  hamamelis  virginica  have  been  useful  in  metror- 
rhagia, I  have  made  quite  a  number  of  trials  with  the  fluid  extracts 

*  [Pravaz  syringe — holds  one  gramme. — Tr.] 


274  DISEASES  OP  THE  STOMACH. 

of  these  drugs  in  bleeding  from  the  stomach ;  but,  since  I  have 
never  seen  any  palpable  benefits  from  them,  I  have  returned  to  the 
use  of  ergotin,  morphine,  and  ice. 

Should  symptoms  of  collapse  appear,  we  may  give  hypodermic 
injections  of  camphor  and  ether  (1 :  6),  or  enemata  of  wine  or  wine 
and  egg  or  peptone,  and  also  hot  applications  to  the  extremities. 
In  threatened  death  from  haemorrhage,  with  very  small  pulse, 
anaemic  murmurs  heard  over  the  heart,  and  cerebral  anemia,  we 
proceed  to  transfusion  of  blood  or  infusion  of  salt  solution.  The 
advantages  of  these  two  methods  have  been  extensively  discussed,  but 
they  have  not  yet  been  finally  decided,  although  lately  there  is  an 
increase  in  the  number  of  cases  successfully  treated  by  salt  infusion*. 

Peritonitis  due  to  perforation  demands  the  exhibition  of  large 
doses  of  opium,  best  given  in  suppositories  or  enemata,  and  also  the 
use  of  ice-cold  applications  to  the  abdomen.  If  doubt  exists  whether 
the  stomach  be  full,  an  attempt  may  be  made  to  empty  it  by  means 
of  the  stomach-tube,  after  the  patient  has,  as  far  as  possible,  been 
rendered  incapable  of  i-eaction  by  means  of  a  large  dose  of  mor- 
phine, or  by  the  local  application  of  cocaine.  But  under  all  circum- 
stances we  must  prevent  all  attempts  at  gagging  and  choking,  since 
these  may  lead  to  the  enlargement  of  the  perforation.  At  times 
this  treatment  has  succeeded  in  keeping  the  peritonitis  localized  and 
causing  adhesions,  f 

Finally,  let  me  mention  the  fact  that  operative  treatment  has 
also  been  directed  to  gastric  ulcer,  and  that  it  has  been  successfully 
excised  by  Kleef,  for  instance.  Inasmuch  as  the  uncertainty  of  an 
exact  localization  of  the  ^^lcer  in  the  stomach  must  always  remain 
the  chief  difficulty  in  this  procedure,  the  future  alone  can  show 
how  much  dependence,  beyond  a  mere  fortunate  coincidence,  may 
be  placed  upon  it.  J 


*  For  instance,  Michaelis,  Heftige  Magenblutung  nach  einer  Magenausspiilung 
(wahrseheineich  bei  Ulcus).  Erfolgreiche  Kochsalztransfusion.  Berl.  klin.  Wochen- 
schr.,  1884,  No.  25. 

f  Such  eases,  which  were  verified  by  the  subsequent  perforation  of  a  second  ulcer 
and  post-mortem  examination,  have  been  reported,  for  instance,  by  Hughes,  Hilton, 
and  Ray,  Guy's  Hosp.  Rep.,  vol.  iv,  and  by  Bennett,  Clinical  Medicine,  p.  487. — [See 
Hall,  loc.  cit.,  on  page  252. — Tr.] 

X  [See  W.  Nissen.    Zur  Prage  der  Indicationen  der  operativen  Behandlung  des 


TEEATMENT  OF  GASTRIC  ULCER.  275 

And  now,  finally,  my  views  of  the  treatment  at  the  mineral 
springs. 

For  years  the  hot  Glauljer  salt  springs,  especially  those  in  Carls- 
bad, have  enjoyed  the  established  and  undeniable  reputation  that 
the  treatment  of  ulcer  there  is  crowned  by  excellent  results.  We 
can  not  assert,  as  we  can  in  other  affections  and  concerning  other 
places,  that  these  results  would  have  appeared  in  spite  of  Carlsbad ; 
nevertheless,  it  is  my  opinion  that  the  same  or  perhaps  more  rapid 
effects  would  have  been  obtained  in  these  cases  had  they  taken  the 
rest-cure  at  home,  and  if  after  its  completion  they  had  sojourned  in 
an  invigorating  climate  under  a  tonic  regimen.  For  the  adjuncts 
of  the  medicinal  springs — pure  air,  diversion,  and  beautiful  scen- 
ery— which  are  frequently  so  effectual,  are  not  requisite  in  the 
treatment  of  gastric  ulcer.  Rest  and  effective  local  treatment  are 
the  things  needed,  and  these  can  be  had  much  better  at  home  than 
anywhere  else.  There  is  always  time,  after  the  disturbances  of  the 
digestive  apparatus  have  been  quelled,  for  the  patients  to  seek  gen- 
eral strengthening  and  invigoration  by  a  stay  at  Franzensbad,  El- 
ster,  Kippoldsau,  Pyrmont,  etc.,  in  the  mountains  or  at  the  sea- 
shore, but  always  with  the  proviso  that  they  are  able  to  procure 
suitable  food,  preferably  by  having  the  family  cook  its  own  meals. 
In  this  regard  the  places  along  the  Baltic  are  to  be  recommended, 
as  all  opportunities  for  keej^ing  one's  own  house  are  there  offered. 
But  very  many  patients  much  prefer  to  go  to  the  baths  or  springs 
than  to  lie  in  bed  at  home,  and  many  too  can  devote  only  from  four 
to  six  weeks  to  the  treatment ;  for  these  Carlsbad  is  the  best  place, 
if  for  no  other  reason  than  that  ojoportunities  for  dietetic  errors  are 
practically  excluded  there.  After  Carlsbad,  IS'euenalir,  Ems,  Franz- 
ensbad, and  Ilomburg  can  be  recommended. 

runden  Magengeschwiirs.  St.  Petersburg,  med.  Wochenschr.,  1890,  Ixiv,  S.  516.  Also 
Simon  and  Barling.  Perforation  of  Gastric  Ulcer  and  its  Treatment  by  Abdominal 
Section. — Brit.  Med.  Jour.,  January  9, 1892. — Tr.] 


276  DISEASES  OF  THE  STOMACH. 

APPENDIX. 

The  Vomiting  of  Blood. — In  addition  to  hsematemesis  in  ulcer 
and  cancer  of  the  stomach,  the  two  diseases  which  undoubtedly  most 
often  give  rise  thereto,  I  will  also  discuss  the  rarer  causes  of  gastric 
haemorrhages. 

The  symptoms  are  fully  given  on  pages  245  et  seq.,  so  that  I  must 
only  add  two  phenomena  which  have  not  yet  been  mentioned. 
These  are  oedema  of  the  extremities,  which  appears  chiefly  at  night 
after  the  patient  has  been  on  his  feet  all  day ;  and  am.aurosis,  appear- 
ing innnediately  or  a  short  time  after  the  haemorrhage,  wdiicli,  ac- 
cording to  Fries,*  is  found  in  65*5  per  cent  of  all  such  cases  of 
hasmorrhage  of  the  intestinal  tract.  Nevertheless,  its  intrinsic  con- 
nection with  haematemesis  has  not  yet  been  made  clear. 

But  as  "  vomiting  of  blood  "  is  applied  not  only  to  gastric  but 
also  to  pulmonary  haemorrhages,  we  may  consider  the  differences 
between  them — i.  e.,  between  hoBmatemesis  and  hcemoptysis.  We 
must  remember  that  in  haemoptysis  the  blood  is  mixed  with  a  great 
deal  of  air,  and  consequently  tends  to  be  bright  red  in  color,  and  is 
ejected  by  coughing,  and  also  that  the  history  points  to  some  chronic 
pulmonary  affection.  In  many  cases  the  patients  have  a  distinct 
sensation  as  to  whether  the  blood  comes  from  the  lungs  or  from  the 
stomach ;  in  the  former  the  haemorrhage  is  preceded  by  inclination 
to  cough,  dae  to  irritation,  tickling  in  the  throat,  and  a  sensation  of 
warmth  in  the  chest,  while  in  gastric  haemorrhages  nausea  and  a 
tendency  to  vomit  precede  the  attack.  This  holds  true  also  of 
pharyngeal  haemorrhages,  which  may  possibly  come  into  play  here ; 
but  these,  as  a  rule,  are  not  so  profuse,  their  source  can  usually  be 
easily  discovered,  and  the  attack  generally  occurs  under  circum- 
stances which  do  not  permit  their  being  mistaken.  However,  gas- 
tric haemorrhages  may  begin  very  violently,  coughing  being  caused 
by  the  aspiration  of  blood  into  the  respiratory  tract,  which  is  ex- 
pelled not  only  through  the  mouth  but  also  through  the  nose.  Thus 
a  pulmonary  haemorrhage  may  be  simulated,  and  even  suffocation 


*  S.  Fries.     Beitrage  zur  Kenntniss  der  Amblyopie  und  Amaurose  nach  Blut 
verlusten.     Inaiig.  Diss.,  Tubingen,  1876. 


H^MATEMESIS.  277 

produced  by  blood  accumulating  and  clotting  in  the  throat  during- 
syncope.  According  to  Henoch,*  a  diiferential  sign,  regardless  of 
the  proof  of  possible  pulmonary  disease,  is  the  acidity  of  the  serum 
in  gastric  haemorrhages,  and  its  alkalinity  in  bleeding  from  the  lungs, 
I  have  had  no  experience  with  this,  but  for  obvious  reasons  I  do  not 
consider  it  applicable  in  cases  of  larger  haemorrhages  rapidly  fol- 
lowed by  vomiting.  Of  far  greater  significance  in  the  differential 
diagnosis  is  the  behavior  of  the  patients  after  the  occurrence  of  the 
attack.  In  hasmoptysis  the  patients  cough  for  some  time  and  the 
sputa  are  coin-shaped  and  brownish  or  brownish-red  in  color ;  in  a 
recent  attack  we  first  observe  bright-red  and  then  dark  blood. 
There  is  no  sputum  after  h^matemesis,  but,  as  a  rule,  we  find 
bloody  stools  (i.  e.,  so-called  melsena),  which  in  doubtful  cases  indi- 
cate the  occurrence  of  gastric  haemorrhage.  On  the  other  hand,  we 
naturally  dare  not  forget  that  many  gastric  haemorrhages  occur  with- 
out bleeding  from  the  intestine,  and  also,  that  occasionally  blood 
which  has  been  coughed  up  is  swallowed  and  voided  in  the  stools. 

The  causes,  then,  which  lead  to  haematemesis,  disregarding  ulcer 
and  carcinoma,  are : 

1.  Conditions  of  congestion  in  the  'venous  vascular  systeiti. 
Thus  Dr.  Yellowly  f  reports  a  case  of  haemorrhage  into  the  stomach 
in  a  man  who  was  hanged  (at  all  events,  there  was  no  haematemesis). 
Similar  occurrences  are  said  to  take  place  in  epileptic  attacks. 
Cases  of  haematemesis  with  cardiac  lesions  have  been  described  by 
Carswell  and  Budd.:{:  H.  Jones  *  has  reported  a  case  in  acute  yel- 
low atrophy  of  the  liver,  and  another  in  cirrhosis  of  the  liver  with 
compression  of  the  portal  vein.  Debove  ||  has  published  an  exhaust- 
ive essay  upon  the  relation  between  haematemesis  and  diseases  of  the 
liver.  Here  especial  attention  must  be  paid  to  the  haemorrhage  from 
dilated  (Esophageal  veins.  In  hepatic  cirrhosis  these  vessels,  which 
form  a  part  of  the  collateral  circulation  for  the  blood  in  the  portal 

*  Henoch.    Klinik  der  Unterleibskrankheiten,  S.  432. 
t  Med.-chirurg.  Transactions,  1853. 

X  Loc.  cit.,  p.  53. 

*  H.  Jones.    Cases  of  Haematemesis,  with  Remarks.     Med.  Times  and  Gazette. 
1855,  vol.  ii,  pp.  183,  410. 

I  Debove.  Des  hemorrhagies  gastro-intestinales  profuses  dans  la  cirrhose  du 
foie  et  dans  les  autres  affections  hepatiques.    Journ.  Soc.  anatom.,  1890,  No.  43. 


278  DISEASES  OF  THE  STOMACH. 

vein,  are  liable  not  alone  to  well-marked  varicosities  but  also  to  rupt- 
ures which  ma}'  cause  profuse  and  at  times  even  immediately  fatal 
hgemorrhages.  These  conditions  have  been  yerj  thoroughly  studied 
by  Blume,  of  Copenhagen,  and  Saundby  and  Wilson,*  of  Birming- 
ham. Yomiting  of  blood  is  also  said  to  occur  in  intermittent  fever, 
but  in  the  cases  described  the  existence  of  an  ulcer  is  not  excluded, 

2.  Active  ki/percemia.  An  example  of  this  is  found  in  the  fre- 
quently quoted  case  of  Watson,  f  concerning  a  woman  who,  ever 
since  her  fourteenth  year,  had  gastric  haemorrhage  instead  of  men-- 
struating,  which,  after  her  marriage,  only  ceased  during  pregnancy 
and  lactation,  and  then  became  vicarious  as  before.  The  following 
case,  which  came  under  my  observation,  must  also  be  considered 
among  the  active  hypersemias.  The  patient  was  a  married  lady  of 
an  excellent  family,  who  again  became  pregnant  after  having  already 
borne  two  children,  the  younger  of  which  was  one  year  old.  One 
evening,  in  order  to  bring  about  a  miscarriage,  she  drank  a  hot  de- 
coction consisting  of  a  bottle  of  claret,  chamomile  flowers,  juniper 
berries,  and  some  powerful  aromatics,  and  also  took  a  vaginal  in- 
jection of  soap-water.  During  the  night,  while  nursing  the  baby, 
she  suddenly  fainted  and  vomited  large  quantities  of  fresh  blood. 
This  was  followed  by  rectal  tenesmus  and  the  evacuation  of  bloody 
masses.  The  hsematemesis  recurred  twice  during  the  next  three 
days.  Although  she  was  greatly  prostrated,  she  made  an  excellent 
recovery  under  appropriate  treatment.  Strange  to  say,  she  did  not 
abort !  Here,  too,  the  hgemorrhages  in  severe  chronic  glandular 
gastritis  are  to  be  included,  which  probably  may  be  regarded  as 
analogous  to  the  bleeding  in  chronic  catarrh  of  the  nose  and  phar- 
ynx. Usually  they  are  so  slight  that  they  do  not  cause  vomiting  of 
blood.  Finally,  we  may  also  include  the  rarer  hsematemesis  in 
hysterical  subjects,  in  cholera,  yellow  fever,  scurvy,  and  purpura 
hsemorrhagica,  so  far  as  the  haemorrhage  is  not  dependent  upon 
direct  lesions  to  the  vessels,  or  upon  changes  in  their  walls. 

3.  Direct  traumatisms.  Haf  ner  :j:  reports  the  case  of  a  boy  who 
half  an  hour  after  a  fall  from  a  considerable  height  on  hard  ground, 

*  Wilson.     Brit.  Med.  Journ.,  1890. 
t  Cited  by  Budd,  loc.  cit.,  p.  364. 
X  Cited  by  Henoch,  S.  434. 


H^MATEMESIS.  279 

without  apparent  external  injury,  repeatedly  vomited  blood,  and  liad 
bloody  stools.  The  swallowing  of  pointed  objects,  and  even  severe 
vomiting  itself,  without  any  further  injury,  may  lead  to  gastric 
hsemorrhage. 

4.  Alterations  in  the  walls  of  the  llood-vessels.  As  yet  nothing 
is  known  concerning  the  formation  of  varices  or  of  atheromatous  or 
amyloid  degeneration  of  the  gastric  vessels,  which  might  lead  to 
hsemorrhages.  As  already  stated,  varicose  veins  occur  in  the  cesoph- 
agus  in  old  persons,  and  also,  as  stated  by  Le tulle,*  in  confirmed 
drunkards.  Bleeding  from  these  vessels  may  give  rise  to  false  hsem- 
orrhages  from  the  stomach.  I  have  found  two  cases  reported  by 
Gallard  f  as  examples  of  the  only  disease  which  can  be  classed  un- 
der this  heading,  in  which  small  miliary  aneurisms  were  the  cause 
of  rapidly  fatal  and  very  profuse  gastric  haemorrhage.  Both  pa- 
tients were  men,  twenty-five  and  fifty-one  years  old  respectively. 
Atheroma,  or  other  diseases  of  the  general  vascular  system,  were 
said  not  to  be  present.  An  additional  case  was  recently  reported  by 
"Welch : :{:  in  a  man,  fifty  years  of  age,  he  found  a  ruptured  miliary 
aneurism  on  a  branch  of  the  gastric  artery;  it  was  situated  in  the 
submucosa,  midway  between  the  pylorus  and  cardia.  I  might,  per- 
haps, include  here  the  cases  already  mentioned  as  occurring  in 
scurvy,  purpura  hgemorrhagica,  yellow  fever,  and  also  in  progressive 
pernicious  anaemia,  malaria,  and  the  exanthematous  fevers ;  although 
we  have  as  yet  no  knowledge  of  demonstrable  alteration  in  the  vas- 
cular walls  referable  to  these  processes.  However,  where  a  positive 
and  extensive  change  in  the  vessels  exists,  as  for  instance  in  the 
atheroma  of  old  persons,  it  does  not,  according  to  my  experience, 
lead  to  gastric  hsemorrhage. 

It  is  apparent  that  the  recognition  of  the  cause  of  the  hsemor- 
rhage necessitates  different  lines  of  treatment,  and  that  it  can  not  be 
an  indifferent  matter,  either  for  the  prognosis  or  the  treatment, 
whether  the  hsematemesis  be  due  to  a  congestion,  or  an  active  hy- 


*  Latiille.  Yariees  veineuses  de  I'cesophage  dans  I'alcoolisme.  Jour,  des  societ. 
Scient.,  1890. 

f  Gallard.  Alterations  pen  connues  dela  muqueuse  de  Testomac.  Gaz.  d.  hopit., 
1884,  p.  196. 

X  Welch.    Johns  Ilopkins  Hospital  Bulletin  No.  1. 


280  DISEASES  OP  THE  STOMACH. 

persemia,  or  a  destructive  process  acting  on  the  mucous  membrane. 
In  tlie  former  it  will  hardly  ever  be  necessary  for  us  to  resort  to 
energetic  antiphlogistic  measures,  which,  at  most,  could  only  be 
indicated  by  the  presence  of  a  very  hard  pulse  with  high  tension, 
and  signs  of  general  plethora,  for  mild  aperient  measures  will  suf- 
fice ;  nor  on  the  other  hand  would  we  apply  all  the  styptics  at  our 
command,  by  means  of  which  we  treat  the  gastric  haemorrhages 
due  to  destructive  processes  {vide  p.  273),  Applications  of  cold 
water  over  the  epigastrium,  possibly  one  or  two  leeches  applied 
there,  swallowing  small  pieces  of  ice,  Haller's  acid  elixir,*  alum- 
whey,  Eochelle  salts,  or  small  doses  of  rhubarb  with  sulphate  of 
soda,  dissolved  in  water,  usually  suffice ;  but,  in  order  to  avoid  re- 
lapses, they  must  be  combined  with  a  carefully  regulated  diet. 

*  [^HaUersches  Sauer,  mistura  sull'urica  acida  (Ph.  Gerra.),  consists  of  a  mixt- 
ure of  1  part  of  sulphuric  acid  (sp.  gr.  1-84)  and  3  parts  of  alcohol. — Tr.] 


LECTUKE  YII. 

INFLAMMATION  OF  THE  COATS  OF  THE  STOMACH  —  GASTEITIS  GLANDU- 
LARIS ACUTA,  IDIOPATHICA  ET  SYMPATHETICA — GASTRITIS  PHLEGMO- 
NOSA   PURULENTA GASTRITIS   TOXICA. 

Gentlemen  :  Tlie  following  remarks  should  Katurallj  have  been 
placed  at  the  commencement  of  this  series  of  lectures,  for  inflam- 
mation of  the  gastric  mucous  membrane  is  almost  constantly  asso- 
ciated with  all  the  affections — at  least  all  the  organic  affections — of 
the  stomach ;  therefore  its  discussion  should  form  the  basis  for  all 
further  remarks.  However,  the  desire  to  incorporate  into  this 
chapter  the  very  latest  experiences  on  this  subject,  which  has  very 
recently  been  the  field  of  numerous  investigations,  has  induced  me 
to  place  the  acute  and  chronic  inflammations  of  the  mucous  mem- 
brane of  the  stomach  after  the  disorders  already  discussed. 

I  shall  preface  the  following  pages  with  a  few  statements  of  a 
general  nature. 

The  Mutual  Relations  of  the  Stomach,  Liver,  and  Intestines. — In 
his  lectures  on  general  pathology  Cohnheim  very  properly  says  that 
it  is  a  characteristic  feature  of  diseases  of  the  stomach  that  one  and 
the  same  factor  tends  to  disturb  the  phenomena  of  digestion  in  so 
many  different  ways.  In  fact,  the  absorption,  secretion,  and  move- 
ments of  the  stomach  have  such  a  close  and  interchangeable  con- 
nection that  under  all  circumstances  injury  to  the  one  also  involves 
the  others.  Every  alteration  of  the  secretion  (e.  g.,  following  an 
acute  gastritis)  changes  the  normal  course  of  those  functions  known 
to-day  by  the  designation  of  the  chemisimis.  But  unalterably 
connected  with  every  disturbance  of  the  chemismus  we  find  also 
changes  in  absorption  and  peristalsis.  For,  should  the  secretion  of 
acid  and  pepsin  be  insufficient,  there  is  not  only  a  retardation  in  the 
formation  of  absorbable  nitrogenous  substances,  but  also  the  degree 

(281) 


282  DISEASES  OP  THE  STOMACH. 

of  acidity  necessary  for  efficient  peristalsis  and  tlie  transfer  of  the 
chyme  into  the  intestines  is  attained  either  very  late  or  not  at  all. 
The  ingesta  stagnate  and  undergo  abnormal  decomposition,  the 
j)roducts  of  which  not  only  further  irritate  the  gastric  mucosa,  but 
also  alter  the  conditions  of  absorption  and  exert  a  paralyzing  influ- 
ence upon  the  muscularis,  either  by  their  absorption  into  the  ves- 
sels or  by  the  mechanical  distention  of  the  organ  with  gases.  Fur- 
thermore, deficient  muscular  action  has  a  depressing  effect  on  the 
intensity  of  absorption ;  insufficient  absorption  leads  to  stagnation 
in  the  venous  system,  and  this  in  turn  to  impairment  of  the  secre- 
tion. Thus  a  vicious  circle  is  formed,  and  one  can  easily  appreciate 
that  there  is  no  difference  at  which  end  of  the  chain  you  be- 
gin ;  for  unless  the  deficiency  of  one  function  is  compensated  by 
the  increased  action  of  the  others  all  the  resulting  phenomena  will 
also  be  developed,  whether  the  first  change  was  in  the  secretion, 
motion,  or  absorption.  If  we  succeed  in  breaking  this  endless  chain 
of  deleterious  influences  at  one  place,  we  effect  a  cure  of  the  remain- 
ing functions — that  is,  provided  the  primary  cause  no  longer  acts. 
This  gives  a  partial  explanation  of  the  fact  that  so  many  cases  of 
what  had  been  to  the  present  time  designated  catarrh  were  cured 
by  the  most  varied  modes  of  treatment. 

But  the  question  arises.  May  not  such  a  regulation  take  place 
without  our  aid  and  without  therapeutic  interference  ?  Cohnheim 
believed  that  this  does  not  occur  in  the  great  majority  of  cases,  and 
he  regarded  this  as  a  characteristic  peculiarity  of  the  diseases  of  the 
stomach  in  which,  for  instance,  much  to  their  disadvantage,  they 
differ  from  cardiac  affections.  On  the  other  hand,  I  believe  that 
such  regulation  frequently  occurs,  and  that  it  is  only  by  such  a  com- 
pensation that  the  manifold  direct  and  indirect  disturbances  to 
which  this  viscus  is  constantly  subjected  are  equalized.  Only  on 
the  disappearance  of  this  compensation  do  we  encounter  what  has 
been  collectively  designated  dyspepsia.  Careful  consideration  will 
show  that  the  heart  and  stomach  are  under  the  same  laws  as  regards 
compensation ;  there  is  only  this  difference,  that  in  the  heart  it  is 
of  long,  frequently  very  long  duration,  while  in  the  stomach  it  is 
only  transitory.  The  heart  passes  from  the  condition  of  compensa- 
tion to  that  of  absolute  insufficiency  ;  while  the  stomach,  on  the 


RELATIONS  OF  STOMACH,  LIVER,  AND  INTESTINES.        283 

other  hand,  may  return  to  the  normal.  In  the  heart  this  compensa- 
tion occurs  but  once,  and  its  existence  can  be  objectively  demon- 
strated, while  in  the  stomach  it  is  merely  transitory  and  can  only  be 
recognized  ex  eventa.  But  if  the  heart  muscle  is  diseased,  or  if 
severe  organic  lesions  are  present  in  the  walls  of  the  stomach,  then 
neither  in  the  one  case  nor  in  the  other  can  there  be  any  more 
thoughts  of  compensation.  Nevertheless,  even  very  marked  dis- 
turbances of  individual  functions  of  the  stomach  may  be  compen- 
sated by  the  increased  work  of  another.  How  else  could  we  exj)lain 
the  fact  that  persons  with  a  complete  absence  of  hydrochloric-acid 
secretion  may  live  for  years  without  marked  dyspeptic  difficulties  % 
Of  this  condition  I  have  observed  a  large  number  of  cases.  The 
explanation  of  this  condition,  which  at  first  glance  appears  so  anom- 
alous, is  to  be  found  only  in  the  increased  peristalsis  of  the  stomach 
by  which  the  ingesta  are  transferred  to  the  intestines  before  they 
can  decompose  or  before  any  other  disturbance  may  occur.  Here, 
doubtlessly,  a  vicarious  compensation  comes  into  play. 

But  it  will  not  suffice  to  simply  call  special  attention  to  the  indi- 
vidual manifestations  of  the  stomach's  functions,  however  obvious 
and  positive  the  fact  may  be.  A  tJiorough  comprehension  of  the 
morhid  processes  of  the  stomach  and  of  the  manifestations  of  the 
disturbance  of  gastric  digestion  is  not  to  he  obtained  without  a  con- 
sideration of  the  relations  existing  between  the  stomachy  the  intes- 
tines, and  the  liver.  For  every  disease  of  the  stomach  affects  the 
intestines  and  liver,  and,  mce  versa,  every  disorder  of  the  latter  is 
reflected  upon  the  former.  Whether  it  be  that  the  stomach-con- 
tents are  rendered  abnormally  acid  from  the  presence  of  inorganic  or 
organic  acids,  or  because  they  contain  much  undigested  food  mixed 
with  mucus,  such  chyme  will  act  on  the  intestines  as  an  irritating 
foreign  body  until  the  specific  intestinal  secretions,  bile,  pancreatic 
juice,  and  the  succus  entericus  succeed  in  quelling  this  disturbance — 
i.  e.,  by  establishing  normal  digestion  and  absorption  in  these  crude 
masses.  Furthermore,  the  upper  portion  of  the  duodenum  is  espe- 
cially involved,  and  hence  the  functions  of  the  liver  are  disturbed 
in  a  twofold  way  :  first,  purely  mechanically  by  swelling  the  orifice 
of  the  common  bile-duct  (this  simply  causes  a  retardation  in  the 
flow  of  bile,  but  no  true  jaundice) ;  secondly,  by  contaminating  the 


284  DISEASES  OF  THE  STOMACH. 

blood  in  the  portal  vein  with  the  products  of  incomplete  digestion, 
which  slows  the  hepatic  circulation  and  in  turn  retards  the  secretion 
of  bile.  Lauder  Brunton  *  has  shown  that  the  rapidity  of  the  cir- 
culation in  the  excised  liver  depends  very  markedly  upon  the  com- 
position of  the  blood  injected  into  its  vessels.  Retardation  of  the 
hepatic  circulation  necessitates  a  slowing  of  the  biliary  secretion, 
and,  since  the  bile  is  antifermentative  and  digests  fats,  the  intestinal 
digestion  is  doubly  affected. 

A  similar  course  of  events  occurs  when  the  liver  or  intestine  is 
the  viscus  primarily  involved,  with  the  exception  that  the  subse- 
quent course  of  the  process,  so  far  as  the  stomach  is  concerned,  is 
somewhat  different.  It  is  not  so  much  the  fact  that  the  intestines 
are  full  and  offer  a  certain  resistance  to  the  expulsion  of  the  chyme, 
or  even  force  the  intestinal  contents  back  into  the  stomach  ;  it  is 
not  the  reaction  which  each  retarded  peristaltic  wave  in  the  intes- 
tines exerts  on  the  peristalsis  of  the  stomach  ;  but  it  is  rather  the 
obstruction  which  is  caused  in  the  entire  portal  circulation,  pro- 
ducing a  venous  stasis  in  all  the  radicles  of  this  extensive  venous 
system,  the  injurious  effects  of  which  are  manifested  even  in  the 
stomach.  A  venous  congestion  of  this  viscus  is  the  result,  which, 
as  we  have  already  seen,  sympathetically  affects  all  its  functions 
by  the  slowing  of  the  secretion  which  is  associated  therewith. 
Thus,  to  a  certain  extent,  in  every  case  of  dyspepsia,  there  are  two 
endless  circles — the  smaller  in  the  stomach,  the  larger  in  that  viscus 
and  also  the  intestines  and  liver — in  other  words,  the  entire  j)ortal 
system. 

But  the  disturbance  of  the  hepatic  cinulation  has  still  another 
significance.  The  function  of  the  liver  is  not  alone  to  secrete  bile, 
but,  being  interposed  between  the  portal  system  and  the  right  side 
of  the  heart,  it  also  forms  a  kind  of  trap  which  arrests  all  toxic  sub- 
stances absorbed  from  the  intestines  ;  these  it  either  retains  and  only 
gradually  gives  up  in  small  quantities  to  the  circulating  blood,  or  it 
decomposes  these  substances  or  returns  them  to  the  intestines  by 
means  of  the  bile.     We  know  that  this  peculiarity  of  the  liver  ac- 

*  T.   Lauder  Brunton.     On  Disorders  of  Digestion,   their  Consequences  and 
Treatment.    London,  1886,  p.  25. 


RELATIONS  OP   STOMACH,  LIVER,  AND  INTESTINES.        285 

counts  for  the  comparatively  harmless  action  of  snake-poison  or 
curare  when  taken  by  the  moutli.  We  also  know  that  this  is  true 
of  nicotine,  and  must  also  assume  it  in  reference  to  the  toxic  prop- 
erties of  peptone.*  For  if  this  feature  of  the  latter's  action  is  not 
generally  manifested,  as  is  actually  the  case,  it  is  because  the  pep- 
tone has  been  reconverted  into  albumen  while  still  in  the  intestinal 
wall,  or  because  it  enters  the  general  circulation  in  such  minute 
quantities  or  so  slowly  that  it  remains  innocaous,  having  been  stored 
up  in  the  liver  or  converted  into  other  products.  Many  facts, 
especially  the  presence  of  peptone  in  the  23ortal  blood,  indicate  the 
occurrence  of  such  a  draining  action  of  the  liver,  which  fails  as  soon 
as  the  functions  of  the  viscus  are  disturbed.  A  somewhat  similar 
function  is  also  true  of  the  products  of  intestinal  digestion — i.  e., 
those  substances  generated  by  the  intestinal  putrefaction  which  pos- 
sess alkaloidal  properties.  Under  normal  conditions  these  have  no 
effect  on  the  general  system  ;  this  may  be  due  to  a  selective  action 
of  the  intestinal  epithelium  which  prevents  their  absorption,  or  they 
may  be  filtered  out  by  the  liver  as  described  above,  or  the  quantity 
absorbed  may  be  too  minute  to  have  any  toxic  effect. 

All  this  may  be  changed,  even  after  an  excessive  meal,  when 
the  amount  of  peptone  absorbed  is  suddenly  increased.  Apathy, 
dullness,  and  a  slight  drowsiness  are  the  result,  which  we  attempt  to 
counteract  by  the  use  of  stimulants  (coffee,  strong  liqueurs,  etc.). 
Such  products  are  formed  in  much  larger  quantities  as  soon  as,  from 
any  cause  whatsoever,  the  intestinal  digestion  has  become  inade- 
quate. Then  either  the  normal  im.permeability  becomes  impaired 
or  the  action  of  the  liver  is  inadequate,  or  both  may  be  combined ; 
so  that,  whatever  may  be  the  final  cause,  the  toxic  substances  are 
taken  up  into  the  blood  and  give  rise  to  more  or  less  severe  symp- 
toms of  poisoning.  In  the  mild  cases,  which  happily  form  the  ma- 
jority, there  are  only  mild  cerebral  symptoms — fatigue,  languor, 
mental  dullness,  and  headache — especially  in  the  occiput.  In  severer 
cases  the  cardiac  action  is  sympthetically  affected ;  palpitation,  or  an 
intermittent  or  irregular  pulse,  and,  finally,  even  marked  symp- 
toms of  poisoning  may  appear,  possibly  as  the  result  of  the  simul- 

^Vide  Ewald.     Klinik,  etc.,  1.  Theil,  3.  Auflage,  S.  102. 


286  DISEASES  OF  THE  STOMACH. 

taneous  absorption  of  the  gases  of  putrefaction,  a  good  example  of 
which  is  the  well-known  case  reported  bj  Senator.* 

It  thus  becomes  evident  that  only  in  very  few  cases  can  we  speak 
of  disturbances  of  the  digestion  of  the  stomach  which  are  limited  to 
that  viscus,  ?.nd  then  only  in  those  cases  in  which  the  gastric  disor- 
der runs  so  rapid  a  course  that  there  is  no  time  for  the  development 
of  the  general  and  mutual  functional  disturbances  just  described. 
This  occurs  only  in  a  comparatively  few  cases  of  so-called  acute 
gastritis ;  in  all  the  others  there  is  ample  time,  even  though  we 
designate  them  acute. 

Acute  {and  chronic)  inflammations  of  the  gastric  mucous  mem- 
brane are  generally  described  as  acute  (or  chronic)  catarrh  of  the 
stomach,  and  in  this  way  an  entirely  erroneous  concejDtion  of  the 
existing  process  is  created.  According  to  our  present  view,  every 
catarrh  is  nothing  but  an  inflammatory  process,  which  we  call  "  ca- 
tarrh "  if  it  essentially  involves  an  epithelial  and  subepithelial  coat 
with  relatively  few  glandular  elements  ;  in  this  case  the  latter  are 
especially  muciparous  glands.  The  structure  of  the  gastric  mucosa — 
better  designated  the  glandular  layer  of  the  stomach,  or  the  tunica 
glandularis — is  such  that  it  is  out  of  the  question  to  call  it  a  mucous 
membrane  in  the  ordinary  meaning  of  this  term ;  it  is  rather  an 
aggregation  of  numerous  tubular  glands  placed  alongside  of  one 
another,  with  excretory  ducts  and  epithelial  cells.  The  structure  is 
thus  a  glandular  parenchyma  with  its  attributes,  interstitial  connect- 
ive tissue  and  excretory  ducts  ;  it  is  simply  a  peculiar  feature  of  the 
inner  layer  of  the  stomach  that  the  protoplasm  of  the  epithelium  of 
these  excretory  ducts  possesses,  to  a  remarkable  degree,  the  property 
of  becoming  converted  into  mucus ;  in  other  words,  it  is  a  muci- 
nogenous  substance  in  the  same  way  that  the  epithelium  of  the  true 
glandular  tubules  is  filled  with  a  pepsinogenous  material. 

Therefore,  such  being  the  structure  of  the  gastric  "mucous  mem- 
brane," every  inflammatory  process  which  involves  it  necessarily 
also  attacks  the  gastric  glands,  unless  it  is  limited  to  the  excretory 
ducts.     The  latter  is  opposed  to  the  results  of  clinical  observation ; 

*  Senator.     Berl.  klin.  Woehensehr.,  1868,  No.  24.    Emminghaus,  ibid.,  1873,  S 

477. 


SIMPLE  ACUTE  GASTRITIS.  287 

Beaumont's  investigation  on  his  patient,  Alexis  St.  Martin,  sliowed 
that  every  "  catarrh,"  even  the  mildest,  was  accompanied  by  a  dis- 
turbance of  the  secretion  of  gastric  juice,  consequently  by  an  affec- 
tion of  the  glands  themselves.  Thus  the  inflammation  is  not  ca- 
tarrhal but  parenchymatous  and  interstitial;  it  has  nothing  in  com- 
mon with  a  catarrh  except  the  "  flow  "  (the  secretion  of  a  more  or 
less  abundant  but  always  alkaline  transudate  into  the  cavity  of  the 
stomach) ;  but  which  it  far  exceeds,  owing  to  the  .accompanying  dis- 
turbance of  the  specific  secretion.  In  this  respect  I  fully  agree  with 
the  views  expressed  by  F.  A.  Hoffmann,*  and  esjDccially  that,  being 
misled  by  the  term  "  catarrh,"  we  are  generally  too  prone  to  under- 
estimate the  importance  of  these  processes,  |)articularly  when  they 
are  chronic,  and  that  by  thinking,  for  example,  of  a  chronic  pharyn- 
geal catarrh  we  lose  all  proper  standards  of  comparison.  Conse- 
quently, if  in  the  following  pages,  from  the  force  of  habit,  I  should 
speak  of  an  acute  or  chronic  gastric  catarrh,  I  shall  nevertheless 
always  have  in  mind  a  gastritis,  or,  better,  a  gastroadenitis,  which 
pursues  an  acute,  subacute,  or  chronic  course. 

According  to  the  etiology,  we  can  distinguish  the  following  va- 
rieties of  acute  gastritis  :  gastritis  glandularis  acuta  simplex  (acute 
gastric  catarrh),  sympathica,  toxica,  ])hleginonosa,  idiojpathica,  and 
metastatica. 

Simple  Acute  Gastritis ;  Occurrence  and  Etiology. — This  lesion  is 
so  common,  and  its  causes  are  of  such  every-day  occurrence,  that  it 
forms  one  of  the  most  familiar  diseases  with  which  we  are  acquaint- 
ed. Every  acute  gastritis  is  really  a  toxic  gastritis  in  the  sense  of  a 
local  irritation  such  as  is  produced  by  toxic  (i.  e.,  locally  irritating 
and  corroding)  substances.  In  this  same  way  every  overloading  of 
the  stomach  may  be  said  to  act  "  toxically,"  since  every  excess  is  fol- 
lowed by  a  number  of  symptoms  of  irritation  which  finally  cause  an 
acute  inflammation.  E^aturally,  our  conception  of  too  much  is  only 
relative,  and  quantities  of  food  which,  under  normal  conditions,  are 
disposed  of  without  any  delay,  may,  under  abnormal  circumstances, 


*  F.  A.  Hoffmann.     Vorlesungen  iiber  allgemeine  Therapie.    Leipzig,  1885,  S. 
169  et  seq. 


288  DISEASES   OP  THE  STOMACH. 

have  an  injurious  effect.  A  convalescent  gets  an  acute  gastric  ca- 
tarrh after  eating  a  beefsteak  which  he  could  easily  digest  when  he 
is  healthy.  A  man  who  has  almost  starved  to  death  must  return  to 
his  usual  diet  very  cautiously  and  gradually.  Three  of  the  fifteen 
shipwrecked  sailors  of  the  Medusa  died  because  they  ate  too  raven- 
ously after  their  rescue. 

Many  persons  have  a  kind  of  predisposition  to  gastric  catarrh, 
just  as  others  are  afflicted  with  a  predilection  toward  catarrhs  of  the 
nose  and  throat ;  such  people  are  made  ill  both  by  the  quantity  and 
quality  of  certain  articles  of  food  which  have  no  effect  on  a  healthy 
stomach.  In  some  this  predisjDOsition  is  decidedly  hereditary.  Al- 
though none  of  the  text-books  with  the  exception  of  Lebert  mentions 
this  circumstance,  yet  I  have  no  reason  to  doubt  it,  since  too  many 
patients  have  assured  me,  either  spontaneously  or  after  questioning, 
that  the  father  or  mother  had  suffered  from  a  weak  stomach,  or  that 
their  brothers  or  sisters  were  equally  predisposed.  Hoffmann  *  says, 
"  Every  one  has  the  stomach  which  he  deserves  "  ;  nevertheless,  great 
injustice  might  be  done  thereby  to  a  large  number  of  persons  who, 
without  being  dyspeptics,  suffer  from  weak  stomachs.  For  it  is  well 
known  that  there  are  some  patients  (even  though  their  number  is 
small)  who  take  the  greatest  possible  care  of  their  stomachs  year 
after  year,  but  are  nevertheless  unable  to  prevent  an  attack  of  acute 
or  chronic  catarrh  which  could  in  no  way  have  been  surmised  be- 
forehand. 

Irritation  may  be  caused  both  by  the  quality  of  the  food  as  well 
as  its  quantity.  Spoiled  articles  of  food  and  drink  may  even  cause 
inflammation  of  the  mucous  membrane  of  the  stomach,  probably  on 
account  of  the  inflammatory  and  fermentative  action  of  the  microbes 
which  have  been  introduced  with  them  ;  thus  we  might  speak  of  a 
bacillary  infection,  if  by  this  we  understand  quite  generally  that  the 
disturbances  are  to  be  referred  to  the  action  of  the  micro-organisms, 
and  not,  of  course,  to  a  direct  invasion  of  them,  furthermore,  it 
has  frequently  struck  me  that,  in  the  various  cases  in  which  I  have 
had  the  opportunity  of  examining  pieces  of  human  mucous  mem- 
brane while  still  warm  from  the  body,  I  have  never  found  so  much 

*  P.  A.  Hoffmann,  loc.  cit. 


ETIOLOGY  OF  ACUTE  GASTRITIS.  289 

as  a  trace  of  bacteria  in  tlie  tissues,  altliongli  tliey  are  so  abundant  in 
the  contents  of  the  stomach.  Yet  I  must  confess  that  I  have  studied 
this  point  superficially  rather  than  with  great  attention  to  details. 
Meanwhile,  although  in  the  examination  of  six  cases  of  gastritis 
membranacea  diphtheritica  Smirnow  *  found  large  numbers  of  mi- 
crococci and  bacilli  in  the  membranes  lying  upon  the  gastric  mucosa, 
yet  he  could  not  detect  them  in  the  lumen  of  the  glands  or  in  the 
tissues.  But  as  the  abnormal  products  of  decomposition  which  irri- 
tate the  mucous  membrane  of  the  stomach  are  always  due  to  organ- 
ized ferments,  it  is  my  belief  that  acute  gastritis  can  in  this  sense  be 
positively  referred  to  the  action  of  micro-organisms.  It  depends 
only  upon  the  number  introduced  into  the  stomach,  and  upon  the 
question  whether  the  antifermentative  gastric  juice  at  the  iudividu- 
al's  disposal  is  able  to  limit  or  stop  the  decomposition.  Therefore, 
since  we  always  introduce  a  certain  number  of  microbes  with  our 
food,  a  disproportion  must  exist  between  the  two  factors  above  men- 
tioned, the  foreign  intruders  and  the  normal  production  of  acid.  To 
this  disproportion  I  should  also  like  to  refer  the  influence  which 
psychical  factors  and  nervous  disturbances  exert  upon  the  develop- 
ment of  acute  gastric  catarrh.  Under  such  circumstances  weak  gas- 
tric juice  is  secreted,  the  motor  and  expulsive  powers  of  the  stomach 
are  enfeebled  ;  hence  any  causes  of  fermentation  which  may  have 
been  introduced  are  allowed  to  grow  more  rapidly  and  abundantly. 
But,  surely,  there  is  at  no  time  a  lack  of  causes  of  fermentation :  M'e 
are  constantly  introducing  them  in  our  food  and  drink,  and  certainly 
one  of  the  chief  functions  of  the  stomach  is  to  disinfect  the  ingesta 
by  means  of  the  gastric  juice,  and  thus  prevent  abnormal  fermenta- 
tions. Where  this  is  done  insufficiently  or  not  at  all,  we  get  de- 
composition and  the  resulting  symptoms  of  irritation. 

Nevertheless,  I  do  not  think  we  ought  to  ascribe  too  much  im- 
portance to  this .  antifermentative  function.  First,  the  cases  of  vica- 
rious intestinal  digestion,  which  have  already  been  spoken  of  quite 
frequently,  in  which  the  gastric  juice  is  permanently  insufficient  or  at 
least  without  any  hydrochloric  acid,  and  in  which  digestion  goes  on 


*  G.   Smirnow,    Ueber  Gastritis  membranacea  und  diphtheritica.     Virchow's 
Archiv,  Bd.  113,  S.  333. 


290  DISEASES  OF  THE  STOMACH. 

very  well,  prove  that  the  requisite  disinfection  may  be  accomplished 
by  the  intestines,  or  that  its  absence  causes  no  appreciable  damage. 
Secondly,  it  has  been  shown  that  there  is  only  a  limited  and  by  no 
means  extensive  decomposition  in  acute  gastritis,  even  though,  as  it 
seems,  free  hydrochloric  acid  is  regularly  absent. 

Among  the  products  of  fermentation  the  first  to  attract  our 
attention  is  lactic  acid.  The  fact  that  it  is  normally  present  in  the 
beginning  of  the  digestion  of  bread  speaks  against  its  having  any 
peculiar  irritating  qualities,  and  rather  stamps  its  appearance  at  this 
time  as  physiological ;  should  it  persist,  as  we  shall  see  that  it  may 
under  certain  circumstances,  and  be  present  in  large  quantities  in 
the  later  periods  of  digestion,  it  is  then  to  be  regarded  not  as  a 
causal  factor,  but  rather  as  a  result.  Furthermore,  it  is  well  known 
that  we  can  give  lactic  acid  medicinally  [as  in  diarrhoea,  diabetes, 
etc.]  and  in  beverages  (kefir  and  kuniyss),  not  only  without  harm 
but  with  benefit  to  the  stomach.  Furthermore,  I  have  had  the 
opportunity  of  examining  the  stomach-contents  in  several  cases  of 
acute  gastritis,  immediately  after  the  beginning  of  the  attack.  One 
case  concerns  me  personally.  I  was  suddenly  taken  sick  during  the 
night  without  having  committed  any  dietetic  error  and  while  lead- 
ing a  very  quiet  life.  I  had  to  vomit  very  frequently ;  at  first  I 
raised  large  quantities  of  offensive  stomach-contents,  but  later  only 
biliary  mucous  masses.  The  filtrate  of  the  former  contained  no 
free  HCl  and  only  traces  of  lactic  acid,  while  (to  judge  from  the 
reaction)  large  quantities  of  fatty  acids  were  present.  I  examined 
the  substances  which  were  first  vomited  in  three  other  cases  by  in- 
mates of  my  infirmary,  where  acute  gasiric  catarrh  is  of  frequent 
occurrence  after  holidays  or  visiting  days.  The  patients  were  be- 
tween the  ages  of  fifty  and  seventy  years,  and  their  digestion  w^as 
otherwise  good.  At  no  time  did  the  filtrate  of  the  vomited  food 
contain  any  free  HCl,  although  the  reaction  was  faintly  acid  (owing 
to  acid  salts) ;  no  lactic  acid  was  present  in  the  ethereal  extract 
[vide  page  34].  A  slow  digestive  action  was  obtained  after  adding 
enough  HCl  to  give  a  feeble  acid  reaction.  Fatty  acids  could  be 
detected  only  in  very  small  quantities  in  spite  of  the  intense  rancid 
odor.  I  wish  to  lay  particular  stress  upon  the  fact  that  these  exami- 
nations were  made  immediately  at  the  beginning  of  the  gastritis. 


PATHOLOGY  OF  ACUTE  GASTRITIS.  291 

Later  on  we  will  find  only  mucus  and  a  few  fragments  of  food,  or, 
if  the  test-breakfast  has  been  given,  the  pieces  of  the  roll  will  be 
found  undigested,  a  larger  or  smaller  amount  of  lactic  acid  but  no 
HCl.  Therefore,  according  to  these  observations,  there  must  be 
other  substances  than  lactic  acid  which  can  produce  the  irritation 
necessary  to  cause  gastritis.  It  is  at  present  a  matter  of  conjecture 
whether  it  be  the  fatty  acids  or  some  products  of  decomposition  as 
yet  unknown  to  us.  However,  I  can  not  believe,  as  for  example 
Leube  does,  that  the  mechanical  irritation  produced  by  undue  reten- 
tion of  ingesta  will  alone  suffice  to  give  rise  to  gastritis.  It  is  true 
that  we  commonly  speak  of  "  overloading  "  the  stomach ;  but  ought 
an  organ  which  is  normally  adapted  to  tolerate  burdens  of  the  most 
varied  kind,  and  for  unequal  periods  of  time,  be  really  irritated  by 
the  prolonged  pressure  of  food  ? 

Among  the  chemical  irritants  I  also  include  those  which  are  toxic 
in  the  true  sense  of  this  word — i.  e.,  concentrated  or  diluted  acids  or 
alkalies,  and  metals  like  copper,  antimony,  iodine,  arsenic,  phospho- 
rus, etc.  Finally,  I  must  also  mention  thermal  irritation  ;  ingesta 
which  are  too  cold  seem  to  do  more  harm  than  those  which  are  too 
hot.  Although  a  draught  of  cold  water  or  beer  is  often  charged 
with  being  the  cause  of  a  gastric  catarrh,  we  scarcely  ever  hear  of 
any  blame  being  attached  to  ice-cream,  which  is  at  least  equally  cold, 
possibly  because  it  is  not  taken  in  such  quantities  or  is  not  so  hastily 
swallowed.  I  have  already  (page  245)  referred  to  some  cases  illus- 
trating this  point. 

Pathology. — All  clinicians  and  pathologists  complain  that  our 
knowledge  of  the  changes  in  the  mucous  membrane  in  acute  gas- 
tric catarrh  is  so  limited,  because  not  alone  is  it  rare  to  encoun- 
ter a  stomach  with  acute  gastritis  at  the  autopsy-table,  but  also 
because  this  viscus  is  always  removed  from  the  body  many 
hours  after  death,  and  hence  the  post  mortem  changes  which 
manifest  themselves  so  early  and  so  destructively  can  not  be 
excluded.  Consequently  we  must  refer  to  the  experiments  made 
on    animals,    especially   those   of    Ebstein,*   Losch,  f   and   Griitz- 

*  Ebstein.     Ueber  die  Veranderungen  welehe  die  Magenschleimhaut  dnrch  Ein- 
verleibung  Yon  Alkohol  und  Phosphor  erleidet.     Virchow's  Archiv,  Bd.  55,  S.  469. 
f  Losch.     Ueber  die  nach  Einvvirkung  abnormer  Reize  auf  die  Magenschleira- 
19 


292  DISEASES  OP  THE  STOMACH. 

ner,*  and  for  the  human  stomach  to  the  studies  of  Edinger  f  and 
Kupffer,:j;  although  the  latter  do  not  specially  take  up  the  question 
of  acute  gastritis,  but  rather  discuss  the  relations  of  the  principal 
and  parietal  cells.*  Here  the  results  of  the  investigations  of  Vir- 
chow,  Klebs,  Menassein,!  and  more  recently  Marfan  and  Stintzig"^ 
may  be  included.  Recently  Sachs  ()  has  also  published  a  number 
of  remarkable  and  very  interesting  contributions  on  this  subject. 
In  my  opinion,  these  complaints  are  not  entirely  justified,  for  in 
very  many  cases  of  acute  diseases  on  which  autopsies  are  made 
there  exists  an  acute  inflammation  of  the  gastric  mucosa  as  an 
accompaniment  of  the  ante-mortem  disturbances — high  fever,  an- 
aemia— even  if  few  or  no  evidences  of  it  can  be  detected  mac- 
roscopically.  But  the  post-mortem  changes  can  be  reduced  to  a 
minimum  by  washing  out  the  stomach  immediately  after  death  and 
then  filling  it  with  alcohol. 

According  to  my  experience,  a  human  stomach  with  an  entirely 
normal  mucous  membrane  is  among  the  greatest  rarities,  at  least 
after  the  fortieth  year,  and  is  found  only  in  persons  wdio  have  met 
with  a  sudden  death.  I  possess  the  stomachs  of  two  persons,  both  of 
whom  were  instantly  killed ;  one  by  the  entrance  of  a  piece  of  meat 
into  the  larynx,  and  the  other  by  injuries  received  from  machinery. 
I  was  able  to  remove  the  first  stomach  immediately  after  death,  and 
the  second  a  short  time  after,  and  placed  both  in  absolute  alcohol. 
Both  specimens  present  an  exquisite  picture  of  the  normal  gastric 

haut  auftretende  pathologisch-anatomisehen  Veranderurigen.  Allgemeine  Wiener 
med.  Zeitung,  1881,  No.  50. 

*  P.  Griitzner.  Neue  Untersuchungen  iiber  Bildung  und  Ausscheidung  des 
Pepsins  im  Magen.     Breslaii,  1875. 

f  Edinger.  Zur  Kenntniss  der  Driisenzellen  des  Magens,  besonders  beim  Men- 
sehen.    M.  Schultze's  Archiv,  Bd.  17,  S.  209. 

X  C.  Kupffer.     Epithel  und  Driisen  des  menseh.  Magens.     Miinchen,  1883. 

#  Ewald.     Klinik,  etc.     I.  Theil,  3te  Auflage,  S.  72,  etc. 

II  R.  Virchow.  Der  Zustand  des  Magens  dei  Phosphorv^rgiftung.  Virchow's 
Archi\^Bd.  31,  S.  399;  Klebs.  Handbuch  d.  patholog.  Anatomie,  1868,  S.  174; 
Menassein,  Chem,  Beitrage  zur  Fieberlehre.  Virch.  Arch.,  Bd.  55,  S.  452 ;  UfEel- 
mann.  Beobachtungen  an  einem  G-astrotomirten.  Deutsch.  Arch,  f  iir  klin.  Med., 
Bd.  26,  S.  441. 

^  Marfan.  Troubles  et  lesions  gastriques  dans  la  phthisic  pulmonaire.  Paris, 
1887  ;  Stintzig,  Miinchener  med.,  Wochenschr.,  1890. 

0  A.  Sachs.  Zur  Kenntniss  der  Magenschleimhaut  in  krankhaften  Zustanden. 
Arch,  fiir  experiment.  Pathologic,  Bd.  22,  Heft  3,  and  Bd.  24,  Hefte  1,  2. 


PATHOLOGY   OF  ACUTE   GASTRITIS.  293 

mucous  membrane  with  distinct  differentiation  between  tlie  parietal 
and  principal  cells.  On  comparing  sections  from  other  stomachs 
with  these  I  find  that  thej  all  show  more  or  less  marked  changes, 
the  most  conspicuous  of  which  is  an  infiltration  of  the  interstitial 
connective  tissue  with  numerous  round  cells,  which  have  also  wan- 
dered to  the  free  surface  of  the  mucosa.  Sliould  the  gastric  func- 
tions have  suffered  during  the  last  days  of  life,  or  if  the  symptoms 
of  an  inflammatory  condition  have  appeared,  as  is  generally  the  case, 
then  in  most  portions  of  the  fundus  no  difference  between  the  pa- 
rietal and  principal  cells  can  be  detected,  and  instead  we  find  that 
all  the  cells  have  alike  become  granular  and  cloudy,  that  in  part  they 
have  become  separated  from  the  membrana  propria  of  the  glands  and 
have  diminished  in  size.  Here  and  there  we  may  find  cysts  which 
contain  either  the  remains  of  epithelial  cells  or  simj)ly  only  a  lining 
membrane.  The  mucous  cells  are  especially  abundant  in  the  pyloric 
region,  and  extend  down  deeply  into  the  ducts  of  the  glands. 

On  the  whole,  this  description  agrees  with  that  given  by  the 
authors  mentioned  above,  and  the  condition  which  I  have  pictured 
indicates,  first,  that  an  active  inflammatory  irritation  must  exist 
which  expresses  itself  in  an  abundant  cellular  proliferation ;  sec- 
ondly, that  there  is  a  condition  of  continuous  activity  of  the  glandu- 
lar cells  which  does  not  permit  the  secretion  to  collect  in  them,  and 
hence  does  give  the  customary  appearance  of  the  cells  of  the  glands 
in  the  condition  of  rest.  At  least  this  is  the  view  of  the  authors 
mentioned,  so  far  as  they  embrace  Heidenhain's  views. 

I  think  I  ought  to  say  here  that  this  condition  of  the  cells,  which 
is  ascribed  to  continuous  activity,  may  be  produced  equally  well  by 
a  complete  cessation  of  their  function.  For  either  the  secretion  is 
formed  in  the  cell,  and  is  so  rapidly  removed  that  none  can  collect 
there,  or  there  is  absolutely  none  produced.  In  either  case  the  re- 
sulting picture  in  the  cell  will  be  the  same. 

I  will  gladly  concede  an  increased  cellular  activity  in  the  early 
stages  of  acute  gastritis  as  a  result  of  inflammatory  irritation,  but 
this  does  not  necessarily  mean  that  the  product  is  improved  in  qual- 
ity ;  on  the  contrary,  the  stomach  may  pour  forth  a  secretion  which 
is  continuous,  but  is  very  deficient  in  active  constituents.  Let  me 
say  now,  to  anticipate  a  little,  that  in  the  later  stages  in  acute  and 


294  DISEASES  OF  THE  STOMACH. 

chronic  inflammation  this  does  not  apply.  For,  not  alone,  according 
to  a  universal  pathological  law,  do  chronic  inflammations  paralyze 
the  speciflc  function  of  the  involved  viscus,  but  we  also  know  di- 
rectly that  in  chronic  catarrhs,  especially  those  which  are  accom- 
panied by  a  profuse  secretion  of  mucus,  the  secretion  is  markedly 
impoverished  in  its  specific  ingredients,  and  consists  of  pure  mucus. 
Sachs,  in  the  work  already  quoted,  lays  great  stress  on  the  karyoki- 
netic  figures  which  may  be  seen  partly  in  the  leucocytes  in  the  inter- 
glandular  tissue,  partly  in  the  superficial  epithelial  cells,  and  partly 
in  the  cells  of  the  "  mucous  glands  of  the  stomach,"  and  wdiicli  afl'ord 
additional  proof  of  the  active  cell  prolifefation  which  occurs  in  these 
processes.  I  have  repeatedly  seen  indications  of  this  kar^^okinesis, 
but  never  such  distinct  pictures  as  are  drawn  by  Sachs.  So  far  as 
our  present  knowledge  goes,  they  do  not  seem  to  have  any  special 
pathognomonic  significance. 

Macroscopically  the  mucous  membrane  appears  entirely  or  par- 
tially swollen  and  reddened,  and  marked  here  and  there  with  small 
suggillations.  Even  to  this  day  Beaumont's  Canadian  [St.  Martin] 
remains  the  classical  witness  for  the  appearance  of  the  gastric  wall 
in  such  a  condition ;  "  its  surface  was  marked  with  numerous 
white  spots  and  vesicles  like  coagulated  lymph,  between  which  were 
very  dark-red  spots,"  while  food  could  be  found  in  the  hollow  of 
the  pylorus  unchanged  and  surrounded  by  a  capsule  of  yellow  mu- 
cus, as  long  as  four  hours  after  ingestion. 

Symptoms. — Authors,  especially  the  French,  have  taken  great 
pains  to  establish  various  forms  of  acute  inflammation  of  the  stom- 
ach. Thus  Lebert  distinguishes  between  an  acute  gastric  irritation 
due  to  overloading,  indigestion,  and  an  acute  painless  catarrh  with 
disturbance  of  a  more  functional  nature ;  the  latter  he  subdivides 
into  the  afebrile  and  the  infectious  febrile  varieties ;  and  finally  he 
describes  an  acute  inflammatory  catarrh.  On  closer  inspection  it 
will  be  seen  that  these  are  only  artificial  subdivisions,  and  that  it  is 
more  in  accordance  with  ]^ature  to  recognize  only  two  great  groups, 
the  afebrile  and  the  febrile  catarrh.  The  latter  is  simply  an  exag- 
geration of  the  former,  but  it  may  occasionally  follow  so  rapid  a 
course  that  an  acute  febrile  gastritis  with  high  fever  may  be  at 
once  developed. 


SYMPTOMS  OP  ACUTE  GASTRITIS.  295 

Immediately  after  a  manifest  indiscretion  of  diet,  etc.,  nausea 
suddenly  appears,  together  with  a  feeling  of  fullness,  tension  and 
swelling  of  tlie  epigastrium,  tenderness  on  pressure  over  this  region, 
thirst,  anorexia,  and  even  disgust  for  food  ;  accompanying  these,  or 
at  the  onset,  are  the  general  symptoms  of  giddiness,  headache,  flashes 
before  the  eyes,  and  prostration.  In  addition  we  find  the  tongue 
coated ;  at  the  beginning  especially  the  organ  is  often  completely 
covered  witli  a  thick,  tenacious  white  fur,  which  may  be  colored  by 
food  or  drugs,  and  which  retains  the  impressions  of  the  teeth ;  as 
the  disease  advances  it  tends  to  clear  up  at  the  tip  and  edges.  At 
times  hei-pes  labialis  develops.  There  is  diffuse  pain  on  pressure 
over  the  region  of  the  stomach,  and  painful  spasms  may  also  appear. 
The  pulse  is  small  and  rapid,  the  secretion  of  saliva  is  increased,  the 
oesophagus  contracts  painfully  ;  spasmodic  yawning  is  also  some- 
times observed.  The  face  becomes  pale,  the  eyes  are  expressionless, 
the  extremities  cold,  and  a  quite  specific  odor  is  exhaled  from  the 
skin.  Now  nausea  and  vomiting  set  in ;  the  latter,  even  if  it  occurs 
some  time  after  a  meal,  consists  of  the  ingesta  only  slightly  changed, 
and  inclosed  in  thick  masses  of  mucus ;  the  vomit  has  a  flat  or  very 
penetrating  odor,  and  an  exceedingly  bitter  taste.  However,  this  is 
not  due  to  bile,  as  the  common  expression  "  as  bitter  as  gall "  would 
lead  us  to  suppose,  but  to  the  acrid  taste  of  the  peptones,  together 
with  the  fatty  acids,  such  as  we  find  in  every  artificial  digestion — 
e.  g.,  peptonizing  milk.  Fresh  bile  is  not  bitter ;  it  is  tasteless.  I 
have  repeatedly  proved  this  in  cases  in  which  the  introduction  of 
the  stomach-tube,  and  the  efforts  at  bearing  down  having  caused  a 
regurgitation  from  the  duodenum,  pure  bile  (chemically  tested)  has 
been  brought  up.  Lauder  Brunton  has  made  the  same  observations. 
The  vomiting  tends  to  be  repeated  many  times,  and  finally  only 
mucus  and  bile  are  raised.  At  first  it  occurs  easily,  but  later  be- 
comes very  painful,  depending  upon  whether  the  spasms  involve  the 
fundus  or  the  orifices,  thus  rendering  the  act  of  emesis  more  diffi- 
cult, a  point  to  which  Skoda  has  directed  attention.  The  reaction 
of  the  vomited  matter  is  neutral  or  faintly  acid ;  we  never  find  free 
hydrochloric  acid,  but  fatty  and  lactic  acids ;  at  the  same  time  the 
latter  are  not  constant,  their  presence  depending,  as  I  have  said 
above,  upon  whether  the  last  meal  contained  a  large  amount  of  sub- 


296  DISEASES   OF   THE   STOMACH. 

stances  which  can  produce  lactic  acid.  Although  the  bowels  are 
constipated  at  first,  the  passage  of  the  chyme  into  the  intestines  irri- 
tates the  mucous  membrane  of  the  latter,  causing  borborygmi,  which 
may  sometimes  be  heard  even  at  a  distance,  the  expulsion  of  offen- 
sive flatus,  and  watery  stools,  accompanied  by  some  tenesmus. 

Under  proper  care  the  condition  disappears  in  three  to  five  days, 
or  it  becomes  subacute  or  chronic. 

Febrile  catarrh  is  distinguished  from  the  afebi'ile  form  only  by 
the  greater  intensity  of  the  symptoms  and  the  occurrence  of  fever 
from  the  onset.  The  latter  appears  suddenly  and  may  reach  40°  C. 
[104°  Falir.]  or  more.  The  skin  becomes  dry  and  livid  and  the 
rapidity  of  the  pulse  is  increased.  There  is  no  proof,  such  as  is  ac- 
cepted to-da^' — i.  e.,  bacillary  infection — for  the  infectious  febrile 
gastric  catarrh  of  Lebert.  Formerly  these  cases  were  called  gastric 
fever,  and  were  classified  with  typhoid  fever,  but  we  have  since 
learned  to  sharply  differentiate  these  two  conditions,  owing  to  our 
better  knowledge  of  the  nature  of  the  latter.  F.  Schmidt*  at- 
tempted to  "  rescue  "  gastric  fevers's  existence  as  ''  an  infectious  dis- 
ease peculiar  to  itself  "  as  the  result  of  observing  a  small  epidemic 
among  soldiers  that  could  not  be  attributed  to  a  typhoid  infection  ; 
unfortunately,  the  most  important  factor,  the  proof  of  infection,  is 
lacking.  The  same  is  true  of  an  epidemic  among  the  inmates  of  the 
Stuttgart  Orphan  Asylum  described  by  Gussmann,*  in  which  24 
out  of  108  children  (22 '3  per  cent)  were  taken  sick  with  an  acute 
febrile  gastric  catarrh,  running  a  rapid  course,  with  temperatures  as 
high  as  104-6°  C.  [105°  Fahr.].  The  disease  ran  its  course  with  the 
usual  symptoms,  with  one  striking  exception,  namely,  the  color  of 
the  skin  was  at  first  yellowish,  then  more  of  a  greenish  hue,  and 
finally  dark  red.  Here  it  is  very  natural  to  think  of  an  infection, 
especially  as  the  well-known  toxic  causes  could  be  excluded,  and  as 
attacks  of  acute  gastritis  were  very  prevalent  at  the  same  time  in 
the  city  and  among  the  garrison. 

The  diagnosis  of  simple  afebrile  gastritis  is  easily  made.     There 

*  F.  Schmidt.  Zur  Frage  nach  der  Existenz  des  gastrischen  Piebers  als  einer 
eigcnartigen  Krankheit.     Dissertation,  Berlin,  1885. 

f  Gussmann.  Eine  Epidemie  von  acuter  Gastritis.  Wurttemb.  Correspondenz- 
blatt,  1888,  No.  22. 


DIAGNOSIS  OF  ACUTE  GASTRITIS.  297 

can  only  be  a  doubt  as  to  whether  the  stomach  was  primarily  affected, 
or  whether  there  was  at  first  a  catarrh  of  the  duodenum  which  sud- 
denly "  exploded  upward,"  as  it  were,  in  the  form  of  the  symptoms 
of  acute  gastric  catarrh.  But  in  such  cases  the  tongue  is  clean,  as  a 
rule,  and  the  onset  of  the  specific  gastric  symptoms  is  usually  pre- 
ceded for  a  longer  or  shorter  time  by  the  signs  of  irregular  intes- 
tinal digestion.  The  stools  have  been  either  irregular,  or  lessened 
in  quantity,  or  the  color  has  indicated  a  deficiency  in  the  biliary  se- 
cretion. The  result  of  this  sluggishness  of  the  intestines  is  mani- 
fested in  a  reactive  stagnation  of  the  ingesta,  the  duodenum  becomes 
filled  and  keeps  back  the  contents  of  the  stomach  ;  and  thus  without 
any  preceding  dietetic  error  the  symptoms  of  a  gastric  catarrh  sud- 
denly appear.  In  my  own  case  which  I  have  mentioned  above  this 
was  obviously  the  course  of  events,  for  it  is  a  fact  that  the  sudden 
vomiting  was  preceded  by  a  period  of  lessened  intestinal  activit}-. 
Nausea  and  anorexia  continued  for  more  than  twenty-four  hours, 
and  were  only  relieved  after  I  had  provided  for  thorough  evacua- 
tion of  the  bowels  by  means  of  several  fairly  large  doses  of  calomel. 
Such  cases  are  therefore  typical  examples  of  the  reflex  action  of 
the  intestines  upon  the  stomach  which  was  mentioned  at  the  begin- 
ning of  this  lecture. 

In  my  remarks  I  have  often  called  attention  to  the  condition  of 
the  tongue,  and  shall  do  so  frequently  in  the  following  pages.  Is 
the  appearance  of  the  tongue  really  a  mirror  of  the  stomach,  or  has 
it,  as  was  held  for  a  long  time,  nothing  whatever  to  do  with  it ;  and 
is  its  condition  to  be  regarded  simply  as  an  index  of  the  existing 
state  of  the  oral  mucous  membrane  ?  In  Henoch's  Klinik  der  TJn- 
terleibskranhlieiten^^  a  splendid  work  for  its  time,  will  be  found  a 
confirmation  of  the  latter  view  that  the  fur  on  the  tongue  in  dis- 
ease f  denotes  nothing  more  than  a  catarrh  of  the  mucous  membrane 
of  the  mouth,  caused  either  by  direct  local  irritation  (such  as  smok- 
ing, bad  teeth,  periostitis,  angina,  or  drugs),  or  produced  by  spread- 
ing from  other  mucous  membrane — e.  g.,  the  stomach  and  intestines. 


*  Berlin,  1863,  S.  383. 

f  This  does  not  include  the  coating  frequently  found  at  the  base  of  the  tongue, 
in  many  persons,  especially  in  the  morning  and  in  those  who  smoke  excessively, 
which  consists  of  desquamated  epithelium,  detritus,  remnants  of  food,  and  bacteria. 


298  DISEASES  OF  THE  STOMACH. 

This  is  undoubtedlj  true,  and  we  must  always  bear  in  mind  the 
various  factors  which  may  produce  a  coated  tongue  in  order,  in  a 
given  case,  to  distinguish  between  local  and  remote  causes ;  but  the 
uniform  relation  of  the  state  of  the  tongue  and  that  of  the  stomach 
in  all  cases  in  which  a  primary  disease  of  the  mouth  is  out  of  the 
question,  indicates  that  the  existing  relations  must  be  much  deeper 
than  would  be  inferred  from  an  independent  catarrh  which  received 
its  first  impulse  from  the  stomach,  and  persisted  even  after  the  re- 
moval of  the  gastric  trouble.  Surely  an  uninterrupted  reflex  action, 
the  direct  nervous  track  of  which  we  can  easily  trace,  must  exist 
here  ;  and  the  old  physicians  were  undoubtedly  right  in  laying  great 
stress  on  the  appearance  of  the  tongue  as  an  indication  of  the  condi- 
tion of  the  stomach,  and  in  frequently  making  it  serve  as  a  guide  for 
their  treatment. 

Furthermore,  although  the  condition  of  the  tongue,  even  when 
not  coated  in  the  ordinary  sense  of  the  term,  may  be  very  variable, 
yet  it  may  give  some  information  as  to  the  character  or  cause  of  the 
dyspeptic  manifestations.  Thus,  in  ulcer  of  the  stomach,  it  is  almost 
the  rule  to  find  the  tongue  red,  moist,  smooth,  and  with  a  thin  white 
fur  at  its  base.  In  nervous  dyspepsias  and  neurasthenic  conditions 
the  tongue  is  strikingly  pale,  smooth,  moist,  and  of  a  bluish  rather 
than  a  reddish  tinge  ;  at  times  there  are  also  deep  transverse  fissures 
or  depressions  at  the  side  which  look  like  excoriations,  but  are 
smoothly  covered  over  by  the  mucous  membrane;  the  latter  are 
very  annoying.  At  times  the  organ  may  seem  to  be  covered  with  a 
white  fur,  whereas  this  appearance  is  really  only  due  to  an  ansemic 
condition  of  the  filiform  papillse.  In  other  patients  the  tongue 
feels  swollen  or  enlarged,  causing  them  to  make  incessant  attempts 
at  swallowing,  as  if  they  wished  to  get  rid  up  of  some  foreign  body 
in  the  moutli ;  such  a  feeling  is  also  exceedingly  annoying. 

The  recognition  of  acute  fehrile  gastritis  may  at  times  not  be  so 
easy.  It  is  true  that  with  a  little  attention  we  can  not  mistake  it  for 
a  beginning  typhoid,  the  step-like  temperature  curve  of  which  is 
quite  characteristic.  But  meningitis,  peritonitis,  and  hepatitis  may 
begin  in  the  same  way,  so  that  we  can  only  feel  sure  of  our  diagno- 
sis after  waiting  a  little  while.  If  the  gastralgic  pains  in  gastritis 
are  unusually  severe,  but  only  moderately  developed  in  biliary  colic, 


TREATMENT  OP  ACUTE  GASTRITIS.  299 

tlie  acconipanying  gastro-duodenal  catarrli  well  marked,  while  jaun- 
dice is  absent — in  such  a  case  the  diagnosis  may  remain  doubtful, 
unless  the  characteristic  sensitiveness  in  the  right  hypochondrium 
helps  us  out.  However,  these  difficulties  occur  more  frequently  on 
paper  than  they  do  in  practice,  and  diagnostic  errors  here  are  of 
still  less  importance,  since  the  rapid  course  of  the  disease  reveals  the 
true  condition. 

Treatment  of  Acute  Gastric  Catarrli. — If  it  be  true  that  this  dis- 
ease never  occurs  spontaneously,  but  is  always  caused  by  some  irri- 
tation introduced  from  without,  and  that  after  its  removal  the  in- 
flamed mucous  membrane  rapidly  returns  to  the  normal,  the  indica- 
tions for  treatment  can  only  be  to  remove  any  noxious  substances 
and  to  prevent  any  further  disturbance — in  other  words,  to  spare 
the  organ.  But  even  this  the  stomach,  as  a  rule,  does  for  itself. 
The  vomiting  and  the  anorexia  are  ISTature's  cure,  which  will  act 
promptly  provided  it  is  not  hindered  by  overzealous  physicians.  I 
do  not  even  consider  it  necessary  to  use  the  mild  vegetable  aperi- 
ents, especially  the  favorite  emulsion  of  castor  oil,  for  as  a  rule  the 
bowels  move  spontaneously,  and  the  fat  of  the  castor  oil  can  simply 
irritate  the  stomach  still  more.  Under  such  circumstances  it  is 
much  better  to  give  a  Bixiusejndver,'^  or  some  effervescing  citrate  of 
magnesia,  or  a  Seidlitz  powder  ;  furthermore,  a  fast  of  twenty-four 
or  even  seventy-two  hours  is  absolutely  necessary,  and  it  is  only  to 
be  broken  on  the  appearance  of  a  feeling  of  real  hunger.  Few 
things  are  more  foolish  than  the  popular  notion  that  "  we  must  offer 
something  to  the  stomach  "  or  "  you  can't  live  two  days  without 
eating,"  for  the  public  ought  to  have  learned  that  a  man  can  easily 
live  for  a  day  or  two  on  his  own  fat  from  the  example  of  the  cele- 
brated fasters  of  the  past  few  years. 

We  should  only  attempt  to  empty  the  stomach  artificially  when 
spontaneous  vomiting  has  not  occurred,  and  pressure,  fullness,  pains, 
and  dullness  over  the  stomach,  as  well  as  the  belching  of  foul-smell- 
ing gases,  show  that  the  viscus  is  still  full,  and  that  the  natural  re- 
sources of  the  organism  are  not  adequate  to  empty  it  either  by  the 


*  [The  Brausepulver  (Ph.  Germ.)  consists  of  sodium  bicarbonate  10  parts,  tar- 
taric acid  9,  white  sugar  19  parts.     Mix  the  well-dried  powders. — Tr.] 


300  DISEASES  OP  THE  STOMACH. 

mouth  or  the  bowels.  The  simplest  and  best  method  is  to  let  the 
patients  drink  considerable  quantities,  say  i  to  f  litre  [quart],  of 
warm  salt  water,  and  then  to  tickle  the  back  of  the  throat  with  a 
feather  or  the  finger  ;  where  these  fail  the  tube  should  be  intro- 
duced. As  a  result  the  patients  vomit  after  this,  and  we  thus  avoid 
causing  them  any  more  disgust  or  producing  fresh  irritation  of  the 
stomach  by  the  use  of  specific  emetics.  Otherwise  the  best  reme- 
dies are  a  dose  of  apomorphia,  0*25  to  0*50  centigranmie  [gr.  -^-^ 

to  -jV],  or 

]^   Pulv,  ipecac 1*5     [gr.  xxiij] 

Antimon.  et  potass,  tartrat 0'05  [gr.  f] 

M.  Yt.  chart,  no.  j.  Sig.  :  To  be  taken  at  once  or  in  divided  doses. 
In  children  we  may  give  a  teaspoonful  of  syrup  of  ipecac.  Should 
constipation  continue  after  the  first  two  days,  prompt  action  can  be 
obtained  by  administering  some  carbonate  of  magnesia  in  the  form  of 
an  efEervescing  lemonade,  or  a  teaspoonful  of  compound  liquorice 
powder,  or  a  glass  of  Hunyadi  water.  In  such  cases  I  am  very  fond 
of  using  calomel,  given  once  or  not  too  frequently  repeated,  and 
regret  that  with  us  in  Germany,  irrespective  of  its  use  in  children's 
diseases,  it  is  not  prized  as  highly  as  it  is  in  England.  It  possesses  so 
many  advantages — its  mild  purgative  effect,  its  cholagogue  properties, 
its  disinfecting  action  (since  it  is  converted  into  corrosive  sublimate) — 
that  the  idiosyncrasy  of  its  easily  causing  salivation  in  rare  cases  can 
by  no  means  outweigh.  In  adults  it  must  not  be  given  in  too  small 
doses,  about  0*4  [gr.  vj]  repeated  in  an  hour ;  *  it  may  advanta- 
geously be  combined  with  small  quantities  of  aloes  (0*1  [gr.  jss.]  of 
the  extract)  or  colocynth  (0-01  [gr.  i]  of  the  extract).  The  decoc- 
tions of  cortex  frangula  and  also  of  senna,  which  have  been  recom- 
mended, cause  much  more  discomfort  and  pain  in  acute  gastro-duo- 
denal  catarrh  than  in  chronic  cases.  Should  marked  pyrosis  exist, 
it  is  advisable  to  follow  the  old  practice  of  using  alkalies  to  neutral- 
ize the  acids  which  have  been  formed ;  the  best  of  these  is  carbon- 
ate of  soda;  possibly  the  generated  carbonic-acid  gas  has  the  same 


*  [By  using  reliable  tablet  triurates,  small,  frequently  repeated  doses  up  to 
0-15  [gr.  ij]  will  usually  be  ample.  The  combination  of  calomel  and  bicarbonate  of 
soda,  which  has  been  recommended  to  prevent  salivation  and  to  lessen  the  griping, 
will  be  found  to  be  valuable. — Tr,.] 


GASTRITIS  SYMPATHICA  ACUTA.  301 

refreshing  and  stimulating  effect  upon  the  mucous  membrane  as  it 
has  elsewhere ;  or  perhaps — and  this  seems  to  me  to  be  much  more 
probable — the  well-known  good  effect  is  due  to  the  anaesthetic 
action  of  this  gas  which  was  demonstrated  bj  Brown-Sequard.  In 
these  cases  it  is  not  advisable  to  give  magnesia  usta,  for  the  caiistic 
magnesia  is  quite  insoluble. 

Gastritis  sympathica  acuta  is  an  exceedingly  frequent  accompa- 
niment of  numerous  acute  febrile  disorders.  All  the  exanthematous 
infectious  diseases — small-pox,  measles,  scarlatina,  typhus  and  ty- 
phoid fevers — the  croupous  and  diphtheritic  processes,  dysentery, 
pyaemia,  and  puerperal  fever,  may  have  disturbances  of  the  gastric 
functions  associated  with  them.  We  can  directly  prove  that  not  only 
are  they  due  to  reflex  nervous  action  (for  instance,  the  influence  of 
fever  on  the  gastric  juice  proved  by  Hoppe-Seyler  *  and  Manas- 
seinf),  but  also  that  they  directly  alter  the  mucous  membrane.  How- 
ever, I  must  add  that  this  effect  of  fever  on  the  secretion  and  com- 
position of  the  gastric  juice  is  by  no  means  always  present.  It  is  true 
that  I  have  myself  published :{:  some  results  of  my  own  which  agree 
with  Manassein,  that  the  gastric  juice  of  febrile  patients  digests 
more  slowly  than  that  of  healthy  persons,  yet  Sassezki  *  found  that 
in  fever  patients  without  marked  dyspepsia  there  was  no  diminu- 
tion in  the  digestive  power.  That  the  secretion  of  hydrochloric 
acid  need  not  be  specially  changed  has  been  proved  by  Edinger  ||  in 
five  cases  of  fever  (phthisis,  recurrent,  intermittent,  and  typhoid 
fevers).  Klemperer^  and  Schetty^  have  made  similar  observations 
in  phthisical  patients  with  fever.  Eecently  I  used  the  test-breakfast 
on  the  fourth  and  fifth  day  of  fever  in  a  young  woman,  twenty- 
seven  years  old,  who  had  facial  erysipelas  with  a  febrile  movement 


*  Hoppe-Seyler.     Allgemeine  Biologie,  1877,  S.  243. 

f  Manassein,  loc.  cit. 

X  Ewald.     Klinik,  etc.,  I.  Theil,  3.  Auflage.  S.  128. 

**  Sassezki.  Ueber  den  Magensaft  Fiebernder.  Petersburger  med.  Wochenschr., 
1879,  No.  19. 

II  L.  Edinger.  Zur  Physiologie  und  Pathologie  des  Magens.  Deutsch.  Arch, 
fur  klin.  Med.,  Bd.  29,  S.  555. 

^  G.  Klemperer.  Ueber  Dyspepsie  der  Phthisiker.  Berlin,  klin.  Wochenschr., 
1889,  No.  11. 

()  F.  Schetty.  Untersuchung  Uber  die  Magenf unction  bei  Phthisis.  Deutsch. 
Arch.  f.  klin.  Med.,  Bd.  44,  S.  219. 


302  DISEASES  OF  THE  STOMACH. 

up  to  39°  to  40-5°  C.  [102-5°  to  104-9°  F.].  Altliongli  tlie  acidity  was 
low — namely,  24  and  36  respectively — yet  free  HCl  was  present, 
the  digestion  test  with  the  filtered  stomach-contents  took  the  usual 
time,  and  a  retardation  of  the  gastric  digestion  could  only  be  recog- 
nized by  the  presence  of  an  amount  of  propeptone  somewhat  larger 
than  usual.  Up  to  that  time  the  patient  had  received  no  medicines. 
Her  general  condition  was  good,  with  the  exception  of  prostration, 
loss  of  appetite,  and  the  local  trouble.  On  examining  the  stomach 
ten  days  later,  when  the  patient  was  fully  convalescent,  I  found  the 
acidity  to  be  32  and  the  other  chemical  functions  the  same  as  before. 
It  must  remain  a  matter  of  doubt  whether  the  average  normal 
acidity  in  this  case  might  not  be  somewhat  higher,  for  I  did  not 
have  another  opportunity  of  repeating  the  examination.  At  all 
events,  this  case  proves  that  even  with  high  fever  the  gastric  juice 
need  not  be  specially  altered,  and  that  therefore  the  temperature 
j)er  se  neither  directly  nor  indirectly  influences  the  glands  of  the 
stomach. 

This  is  an  additional  reason  for  assmning  an  actual  change  in 
the  mucous  membrane  in  the  above-mentioned  sympathetic  dis- 
orders of  the  stomach.  Although  the  gastric  symptoms  are  relegated 
to  the  background  by  the  other  manifestations,  yet  in  those  cases 
with  dyspeptic  disturbances  in  which  we  are  enabled  to  examine  the 
organ  soon  after  death,  we  will  find  the  anatomical  changes  of  acute 
gastritis. 

In  diphtheria,  variola,  and  scarlatina  even  false  membranes  and 
diphtheritic  ulcers  may  be  formed.*  According  to  Smirnow,  we 
must  here  deal  with  two  forms  of  the  disease.  In  the  one  form 
there  is  a  more  or  less  marked  hyperasmia  Avith  extravasation  and 
desquamation  of  the  glandular  epithelium  without  any  disturbances 
of  the  true  secretory  parenchyma — i.  e.,  a  fibrinous  inflammation  ; 
in  the  other,  the  mucous  membrane  itself  is  attacked  by  a  necrobi- 
otic  process  and  passes  into  the  condition  described  by  von  Reck- 


*  Cahn.  Ein  Fall  von  Gastritis  diphtheritica  bei  Rachendiphtherie  mit  acuter 
gelber  Leberatrophie.  Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  34,  S.  113.— G.  Smirnow. 
Ueber  Gastritis  membranacea  und  diphtheritica.  Virch.  Arch.,  Bd.  113,  S.  356. — 
G.  Kalraus.  Ein  Beitrag  zur  Statistik  und  pathologischen  Anatomic  der  secun- 
dare  Magendiphtheritis.     Inaug.  Dissertation.     Kiel,  1888. 


PHLEGMONOUS  GASTRITIS.  303 

lingliaiiseii  as  hyaline  degeneration  of  the  cellular  elements.  In 
addition,  Kalmus  claims  to  have  found  numerous  bacteria  not  only 
in  the  exudate  and  necrotic  tissue,  but  also  in  the  depths  of  the  still 
sound  tissues,  and  even  in  the  submucosa ;  while  Smirnow,  as  stated 
above,  found  the  tissues  entirely  free  from  them.  Kalmus  found 
gastric  diphtheria  in  6*5  per  cent  of  his  cases  (199).  The  site  of  the 
diphtheritic  ulcers  is  usually  at  the  cardia,  whence  they  spread  in 
radiating  lines  toward  the  fundus.  In  other  cases  we  find,  especially 
at  the  fundus,  small  yellowish  or  brownish  sloughs  surrounded  by  a 
reddened  zone,  or  even  membranes  which  consist  of  fibrin,  mucus, 
desquamated  glandular  cells  and  their  products  of  disintegration,  or 
which  may  be  partly  of  an  exudative  character.  When  they  are 
cast  off  they  leave  deep  losses  of  substance  behind,  and  are  accom- 
panied by  necrosis  of  the  layers  of  the  mucous  membrane  ;  they 
may  also  cause  fatal  hsemorrhages.  This  process  is  naturally  much 
more  than  a  simple  acute  gastritis  ;  furthermore,  even  if  they  do 
not  have  such  severe  results,  the  acute  inflammation  accompany- 
ing the  above-mentioned  diseases  easily  assumes  a  chronic  form,  and 
may  therefore  persist  long  after  the  primary  disorder  has  subsided, 
and  thus  delay  convalescence. 

Acute  gastritis  may  become  subacute  or  chronic.  The  assertion 
that  a  subacute  catarrh  is  always  developed  from  an  acute  attack 
can  only  be  accepted  with  a  reservation.  Many  cases  undoubtedly 
run  a  subacute  form  at  first,  and  become  acute  after  some  severe 
irritation. 

The  French  very  appropriately  designate  subacute  catarrh,  em- 
harras  gastrique,  the  English  call  it  indigestion,  while  we  [in  Ger- 
many] describe  it  as  status  gastricus.  Its  symptoms  and  treatment 
are  so  closely  connected  with  chronic  gastritis  that  their  discussion 
may  be  deferred  to  the  lecture  on  the  latter. 

Suppurative  Inflammation  of  the  Stomach ;  Gastritis  Phlegmonosa 
Purulenta. — This  lesion,  which  is  usually  acute  and  rarely  subacute, 
differs  from  acute  gastritis  in  the  fact  that  it  is  not  situated  like  the 
latter  on  the  glandular  layer  of  the  stomach,  but  in  the  submucosa 
and  muscularis.  The  condition  is  rare,  and  I  can  only  recall  one 
case  of  a  female  servant  whom  I  saw  at  Frerichs's  clinic.     Quite  a 


304  DISEASES  OF  THE  STOMACH. 

number  of  sucli  cases  have  been  publisbed,  especially  of  late,  after 
Andral  and  Cruveilliier,  Rokitanskj  and  Dittrich,  Ilabershon  and 
Brinton  had  described  and  classified  them  :  hence  it  is  not  difficult 
to  obtain  a  complete  description  of  the  disease. 

Occurrence  and  Etiology. — Men  seem  to  be  especially  liable ;  of 
Lebert's  31  cases,  26  were  men  and  5  women.  According  to  Glax  * 
the  number  of  cases  published  since  then  (1878)  would  increase  the 
total  to  51  ;  41  of  these  include  33  men  and  8  women.  It  occurs 
most  frequently  between  the  twentieth  and  sixtieth  years. 

We  may  distinguish  an  idiopathic  primary  and  a  metastatic 
foriYh. 

The  causes  of  primary  phlegmonous  gastritis  are  unknown ;  at 
least  I  can  not  attribute  any  importance  to  the  vague  claims  for 
alcoholism,  dietetic  errors,  traumatisms,  etc.  It  is  just  here,  if  any- 
where in  the  whole  field  of  the  diseases  of  the  stomach,  that  we  can 
assume  that  the  disease  is  due  to  infection,  and,  in  accordance  with 
our  present  knowledge,  to  bacteria.  In  fact,  Ziegler  *  claims  to 
have  found  numerous  streptococci  partly  free  in  the  tissues  and 
partly  inclosed  in  the  cells. 

The  metastatic  form  occurs  in  severe  pysemic,  puerperal,  and 
exanthematous  diseases,  or  is  due  to  an  extension  of  a  perigastric 
phlegmon. 

Pathological  Anatomy. — Circumscribed  abscesses,  gastritis  phleg- 
monosa  circumscripta,  also  called  abscess  of  the  stomach,  must  be 
differentiated  from  diffuse  purulent  infiltration.  As  a  rule  the  ab- 
scesses are  small,  varying  in  size  from  a  pea  to  a  hazel-nut ;  some- 
times they  are  as  lai-ge  as  a  walnut  or  goose-egg.  The  mucous 
membrane  is  raised  over  these  areas,  and  on  cutting  into  it  we  find 
that  the  abscesses  are  in  the  submucosa,  possibly  infiltrating  and 
causing  purulent  liquefaction  of  the  muscularis  and  extending  down 
to  the  serosa.  In  advanced  stages,  perforation  may  occur  into  the 
cavity  of  the  stomach  or  peritongeum.  The  diffuse  infiltration  ad- 
vances in  the  submucous  tissue  and  extends  up  between  the  glandu- 
lar tubules  of  the  mucosa  or  along  the  bundles  of  muscular  fibers  in 

*  J.  Glax.     Die  Magenentziindung.     Deutsch.  med.  Zeitung,  1884,  No.  3. 
f  Ziegler.     Lehrbuch  der  allgeraeine  and  spec,  pathologische  Anatomie,  1887 
[Bd.  2],  S.  516. 


SYMPTOMS  OF  PHLEGMONOUS  GASTRITIS.  305 

tlie  musciilaris  ;  the  muscle-fibres  themselves  undergo  fatty  degenera- 
tion, or  show  proliferation  of  the  nuclei  and  infiltration  with  pus- 
cells.  Cribriform  perforations  of  the  surface  of  mucous  membrane 
now  occur,  through  which  pus  wells  up  on  pressure  ;  or  the  pus 
penetrates  down  toward  the  serosa,  separates  and  perforates  it, 
unless  adhesions  with  the  adjacent  viscera  have  been  formed  as  the 
result  of  preceding  inflammation. 

Symptoms. — In  the  majority  of  cases  the  disease  runs  an  acute  or 
even  foudroy ant  course  ;  a  chronic  form  is  very  rare  indeed.  The 
onset  is  either  sudden,  as  in  the  case  observed  by  me,  or  it  may  be 
preceded  by  vague  dyspeptic  disturbances  ;  it  is  marked  by  exceed- 
ingly violent  and  intense  pain  in  the  epigastrium,  severe  burning 
in  the  stomach,  raging  thirst,  dry  tongue,  and  comjDlete  anorexia. 
From  the  beginning  the  patients  feel  that  they  are  very  ill ;  high 
fever  at  once  sets  in,  the  temperature  reaching  40°  C.  [104°  F.]  or 
more,  with  occasional  chills  and  slight  remissions.  The  pulse  is 
small,  frequent,  or  irregular.  Emesis  is  rarely  absent ;  the  vomit 
consists  of  biliary  or  mucous  masses  or  large  quantities  of  pus.* 
The  sensorium  is  always  severely  affected  ;  the  patients  are  rest- 
less and  anxious ;  in  one  case  observed  by  Lebert  this  condition 
was  so  marked  that  the  sufferer  threw  himself  out  of  a  win- 
dow and  died  at  once  ;  delirium  may  now  appear,  and  the  patient 
dies  in  coma  or  in  general  prostration.  It  is  not  surprising  that 
such  a  clinical  picture  should  resemble  '  acute  articular  rheu- 
matism, and  indeed  we  find  the  following  case  described  by  Mac- 
leod :  f 

A  laborer,  thirty-six  years  old,  was  ill  for  a  fortnight,  apparently  from 
acute  articular  rheumatism.  No  pain  in  the  epigastrium,  no  vomiting. 
Delirium  and  great  restlessness  were  attributed  to  alcoholism.  Died 
comatose.  The  autopsy  showed  that  the  wall  of  the  stomach  in  the  vicin- 
ity of  the  greater  curvature  and  pylorus  was  1"5  centimetre  [|  inch]  thick 
and  contained  large  quantities  of  yellow  pus  between  the  muscularis  and 
submucosa.  The  mucosa  was  unchanged.  There  was  no  inflammation 
of  the  joints  or  any  other  suppurative  processes. 


*  Bukler.  Idiopathisch-phleginonose  Gastritis.  Bayer,  arztliehes  Intelligenz- 
blatt,  1880,  No.  37. 

f  Maeleod.  Suppurative  Gastritis ;  Death ;  Necropsy.  Lancet,  1887,  vol.  ii,  p. 
1166. 


300  DISEASES  OF  THE  STOMACH. 

Grainger  Stewart  lias  observed  iiiiiaiiiination  and  gangrene  of 
tlie  gall-bladder,*  "VY.  Lewin  f  lias  seen  petecliiaB  over  tlie  entire 
body,  those  on  the  right  thigh  reaching  the  size  of  a  hazel-nut ;  there 
was  also  jaundice.  The  autopsy  revealed  multiple  abscesses  between 
the  mucosa  and  serosa  of  the  stomach,  diffuse  purulent  j)eritonitis, 
and  suppurative  pleurisy  on  the  left  side.  Brinton  and  Chvosteck  ^ 
have  also  found  jaundice  in  idiopathic  phlegmonous  gastritis;  it 
might  perhaps  be  explained  by  the  extension  of  the  inflammation  to 
the  duodenum  and  the  mouth  of  the  common  bile-duct,  unless  it  is 
a  pysemic  icterus.*  Glaser  reports  the  very  rare  occurrence  of  this 
disease  in  the  course  of  a  carcinoma  and  an  ulcer  of  the  stomach ; 
in  these  two  cases,  strange  to  say,  vomiting,  which  is  otherwise  so 
constant,  was  absent. 

During  the  course  of  the  disease  there  is  either  absolute  consti- 
pation, or,  what  is  more  common,  diarrhoea  occurs  with  marked 
meteorism  and  gargouillement.  The  duration  is  two  wrecks  at  the 
utmost,  but  it  generally  lasts  a  much  shorter  time.  Lewin's  case, 
quoted  above,  which  lasted  four  weeks,  is  an  exceedingly  rare  ex- 
ception. 

Diagnosis. — You  will  have  seen  from  the  clinical  picture  that  in 
the  majority  of  cases  the  diagnosis  of  this  disease  can  only  be  a 
matter  of  chance ;  for,  on  the  one  hand,  the  process  so  closely  re- 
sembles a  circumscribed  peritonitis,  and,  on  the  other,  perigastric 
inflammations  or  abscess  formation  may  give  rise  to  such  confus- 
ingly similar  symptoms — e.  g.,  arteritis  or  abscess  of  the  left  lobe  of 
the  liver  or  of  the  spleen — that  a  differential  diagnosis  is  absolutely 
impossible. 

I  can  not  agree  wdtli  Deininger  ||  in  considering  that  high  tem- 
perature, constant  pain  in  the  stomach  which  is  not  increased  on 
movement,  and  increased  resistance  in  the  epigastrium,  are  suffi- 
ciently characteristic  points  on  which  to  base  a  diagnosis ;  and  it  is 
my  opinion  that  tlie  doubts  of  the  possibility  of  establishing  a  diag- 


*  Edinburgh  Med.  Journal,  February,  1868. 

t  W.  Lewin.     Berl.  klin.  Wochenschr.,  1884,  S.  73. 

X  Wiener  Klinik,  1881,  and  Wiener  med.  Presse,  1877,  Nos.  22-29. 

»  Berl.  klin.  Woehenschrift,  1883,  S.  790. 

II  Deutsch.  Archiv  f.  klin.  Med.,  Bd.  23,  S.  C28. 


MYCOTIC   GASTRITIS.  307 

nosis,  already  expressed  in  18T9  by  Leu  be,  have  not  been  removed 
by  the  cases  wliich  have  since  been  pubhshed.  Even  if  large  quan- 
tities of  pus  should  be  vomited,  and,  as  happened  in  a  case  of  Callow 
and  also  of  Deininger,  a  previously  palpable  tumor  should  disappear 
after  such  vomiting,  the  presence  of  a  gastric  phlegmon  could  not 
be  positively  asserted.  The  differential  diagnosis  from  typhus  fever, 
which  it  might  resemble  in  its  febrile  movement  and  the  possible 
occurrence  of  petechise,  might  more  readily  be  made  by  the  violent 
and  continuous  pain. 

Treatment  can  only  be  symptomatic — i.  e.,  antij^hlogistic.  Cold 
applications  to  the  abdomen,  possibly  the  use  of  leeches,  swallowing 
pieces  of  ice,  ice-cold  effervescing  mixtures,  hypodermic  injections 
of  morphine,  and  restoratives,  are  the  only  means  at  our  disposal  in 
such  cases. 

Gastritis  Mykotica  et  Parasitaria. — The  little  we  know  about  the 
invasion  of  the  mucous  membrane  of  the  stomach  by  fungi  may 
fittingly  be  discussed  in  connection  with  gastric  phlegmon. 

I  know  of  only  one  case  of  the  invasion  of  the  grosser  fungi, 
namely,  that  reported  by  Kundrat  *  of  a  drunkard  with  f avus  uni- 
versalis, in  which  the  parasites  had  even  penetrated  as  far  as  the 
mucous  membrane  of  the  stomach  and  intestines.  Here  the  fungi 
had  caused  a  diphtheritic  inflammation  with  ulceration  and  slough- 
ing and  fibrinous  exudations.  Kundrat  thinks  that  the  mucous 
membrane  was  predisposed  by  the  drunkard's  chronic  catarrh. 
Death  was  due  to  diarrhoea  which  resisted  all  treatment. 

Some  time  ago  Klebs  f  described  a  hacillus  gastricus  which  oc- 
curred in  a  number  of  cases  ;  it  had  numerous  spores,  and  was  found 
free  in  the  lumen  of  the  glands  as  well  as  between  the  membrana 
propria  and  the  epithelium  of  the  latter.  Unfortunately,  we  have 
learned  nothing  of  the  clinical  features  of  these  cases.  Orth;}: 
reports  a  case  of  gastric  ulcer  in  which  there  were  gray  sloughs 
of  the  mucous  membrane  looking  like  bran  and  containing  ba- 
cilli. 

*  Kundrat.     Ueber  Gastroenteritis  favosa.     Wien.  med.  Blatter,  1884,  No.  49. 
f  Klebs.     Ueber  infectiose    Magenaffectionen.      Allgemeine  Wiener   med.  Zei- 
tung,  1881,  Nos.  29,  30. 

X  J.  Orth.     Lehrbuch  der  spec,  patholog.  Anatomic,  1887,  S.  704. 
20 


308  DISEASES   OF  THE  STOMACH, 

E.  Frankel*  has  reported  a  case  of  emphysematous  gastritis  which 
was  probably  of  mycotic  origin. 

A  laborer,  thirty-five  years  old,  sustained  a  severe  contusion  of  the 
right  hand,  with  crushing  of  the  last  phalanx  of  the  index-flnger.  Under 
appropriate  surgical  treatment  the  patient  did  very  well  ;  hut  on  the  sev- 
enth day  he  suddenly  went  into  collapse,  complained  of  pain  in  the 
stomach,  and  vomited  bloody  masses.  In  sj^ite  of  the  excellent  condition 
of  the  wound,  which  in  no  way  corresponded  to  the  severity  of  the  gen- 
eral condition,  the  sym]Dtoms  persisted  two  days  longer,  when  the  patient 
died  in  collapse. 

At  the  autopsy  it  was  fouDd  that  the  mucous  membrane  of  the  stomach 
was  of  an  intense  red  color  and  was  dotted  with  numerous  bubbles  of  air 
which  had  been  formed  between  the  mucosa  and  the  submucosa.  There 
were  neither  extravasations  of  blood,  nor  losses  of  substance,  either  of 
short  or  long  standing.  Processes  of  putrefaction  were  also  absent.  Mi- 
croscopic examination  of  the  tissue  surrounding  the  bubbles  revealed  nu- 
merous bacteria,  resembling  those  of  anthrax.  They  were  not  found  within 
the  glands  of  the  stomach  or  blood-vessels.  This  tissue  also  had  foci  of 
infiltrations  with  small  cells,  its  vessels  were  filled  to  distention,  and  there 
were  also  microscopic  extravasations  of  blood, 

Friinkel  properly  rejects  the  supposition  that  the  process  was 
one  of  putrefaction  or  the  invasion  of  bacteria  from  the  free  surface 
of  the  gastric  mucous  membrane  ;  he  attributes  it  to  an  involvement 
of  the  gastric  mucosa  by  bacilli  which  had  probably  entered  the 
circulation  through  the  wound,  but  had  not  caused  any  infection  at 
this  point  of  entry. 

The  bacteria  found  in  diphtheria  of  the  gastric  mucosa  have 
already  been  mentioned  (page  303). 

Thus  far  the  clearest  of  all  have  been  the  troubles  caused  by 
anthrax,  in  which  the  bacilli,  as  Ortli  3ays,  "reach  the  stomach 
either  as  such,  or  as  spores  from  without  or  from  the  blood."  They 
cause  marked  swelling  of  small  areas  of  the  mucous  membrane,  and 
especially  of  the  submucosa,  w^th  central  sloughing  and  consecutive 
ulceration. 

The  presence  in  the  chyme  of  sareinse,  yeast-fungi,  and  nu- 
merous micro-organisms  which  have  been  mentioned  in  the  dis- 
cussion of  gastric  fermentation,  never  seems  to  directly  irritate  the 
mucous  membrane  of  the  stomach.     On  the  other  hand,  I  may  add 

*  E.  Frankel.    Virchow's  Archiv,  Bd.  cxviii,  S.  536. 


TOXIC   GASTRITIS.  309 

concerning  foreign  parasitic  organisms,  even  if  tliey  are  not  my- 
cotic, that  Gerliardt  *  rej^orts  an  acute  gastritis  which  was  due  to 
the  invasion  of  larvae  of  dipterse  which  w^ere  probably  swallowed 
with  raspberries,  and  that  Meschedef  has  seen  the  same  disease 
caused  by  maggots  in  cheese.  On  the  other  hand,  Lublinski  :j;  found 
that  no  special  effect  was  produced  by  larvse  of  the  house-fly  which 
had  been  swallowed  in  raw  meat  and  got  rid  of  by  vomiting.* 
A  lono;  time  affo  Fermaud  11  observed  a  somewhat  similar  case  in 
which  gastritis  and  gastralgia  were  caused  by  an  earthworm  in  the 
stomach  ;  it  has  also  been  known  for  a  long  time  that  ascarides  and 
even  teenia  may  wander  into  the  stomach  and  cause  intense  catarrh 
of  this  viscus. 

Gastritis  Toxica. —  I  can  only  give  a  short  review  of  those  poisons 
which  directly  affect  the  gastric  mucous  membrane.  The  com- 
monest are  alcohol,  phosphorus,  cyanide  of  potassium,  arsenic 
(Schweinfurt  green),"^  cori^osive  sublimate,  chlorate  of  potash,  nitro- 
benzol,  concentrated  mineral  acids  (also  carbolic  acid),  and  caustic 
alkalies. 

After  Virchow  ^  had  described  the  fatty  degeneration  of  the 
glandular  epithelium  in  an  interesting  series  of  investigations,  Eb- 
steinj  showed  what  influence  alcohol  and  phosphorus  have  upon 
the  stomach ;  he  also  discovered  the  very  important  fact  that  after 
ingestion  of  these  substances  (which  also  serve  as  prototypes  of  a 
number  of  drugs  with  a  similar  action),  the  macroscopic  changes  may 
be  comparatively  slight,  while  the  finer  structure  of  the  glandular 


*  C.  Gerhardt.  Magenkatarrh  durch  lebende  Dipterenlarven.  Jenaer  med.  Zeit- 
schrift,  Bd.  3,  S.  522. 

f  Mesehede.  Ein  Fall  von  Erkrankung,  hervorgerufen  durch  versehluekte  und 
lebend  im  Magen  verweilende  Maden.     Virchow's  Archiv,  Bd.  36,  S.  300. 

X  W.  Lublinski.  Ein  Fall  von  lebenden  Fliegenlarven  im  menschliche  Man- 
gen,  etc.     Deutsch.  med.  Wochenschr.,  1885,  No.  44a. 

*  [Senator.  Ueber  lebende  Fliegenlarven  im  Magen  und  in  der  Mundhohle. 
Berl.  klin.  Wochenschr.,  1890,  No.  7. — See  also  Hildebrandt.  Erbrechen  von  Flie- 
genlarven.   Ibid.,  1890,  No.  19.— Tr.] 

II  Fermaud.  Observ.  sur  une  eardialgie  accompag.  de  symptomes  de  gastrite 
intense  reconnaissant  pour  cause  la  presence  d'un  ver  terrestre  dans  I'estomac. 
Journ.  de  med.  pratique  de  Paris,  1836,  tome  vii,  p.  57. 

^  [So-called  Paris  green.] 

^  Log.  cit. 

"^Loc.  cit. 


310  DISEASES  OF  THE  STOMACH. 

layer  is  greatly  altered ;  for,  while  macroscopic  examination  showed 
only  a  mild  hypersemia  and  slight  extravasations  of  blood,  the  mi- 
croscope revealed  that  the  epithelium  of  the  vestibule  ( Yorrauni)  of 
the  glands  and  the  glandular  cells  themselves  were  cloudy  and  gran- 
ular and  had  partly  undergone  mucoid  and  fatty  degeneration,  and 
that  the  interglandular  tissue  was  infiltrated  with  small  cells.  Thus 
a  gastritis  glandularis  degenerativa  is  developed,  which  even  in 
favorable  cases  disappears  very  slowly,  and  which  explains  the  pro- 
tracted digestive  disturbance  remaining  after  phosphorus  poisoning 
and  the  influence  of  the  abuse  of  alcohol  on  the  stomach. 

The  corrosive  poisons  act  differently.  I  can  not  here  discuss 
the  classical  picture  of  poisoning  by  sulphuric,  hydrochloric,  and 
oxalic  acids  or  the  caustic  alkalies  ;  I  shall  only  recall  the  fact  that 
their  effects  vary  according  to  the  quantity  taken  and  the  fullness  of 
the  stomach  and  the  nature  of  its  contents  previous  to  the  act  of  swal- 
lowing the  poison.  In  mild  cases  the  destroyed  tissue  is  imperceptibly 
cast  off  and  cicatrization  follows  ;  in  severer  cases  the  mucosa  and 
submucosa  are  cauterized  and  converted  into  a  black  slough,  the  mus- 
cularis  becomes  the  seat  of  a  serous  or  gelatinous  infiltration,  or  is 
charred  down  to  the  serosa ;  then  there  is  perforation  of  the  stomach, 
with  escape  of  its  contents  into  tlie  peritoneal  cavity.  Metallic 
poisons  usually  cause  a  general  inflammation  and  liyperEemia,  or 
they  involve  localized  areas  with  superficial  necrosis.  Excellent 
illustrations  of  these  conditions  will  be  found  in  Lessor's  Atlas.* 

The  symptoms  of  poisoning  naturally  vary  according  to  the  na- 
ture of  the  substance  taken :  if  it  be  one  of  the  group  of  caustic 
fluids,  its  effects  will  be  manifested  in  the  mouth,  pharynx,  and 
oesophagus.  But  the  acute  action  on  the  stomach  can  also  be  readily 
recognized  in  the  group  of  symptoms  in  poisoning ;  for  the  sudden 
onset  of  all  the  symptoms,  the  repeated  vomiting  which  can  hardly 
be  allayed,  the  vomit  mixed  with  bloody  mucus  or  pure  blood,  the 
intense  pain  in  the  stomach  which  is  increased  on  vomiting,  the 
profound  collapse,  the  change  in  the  features  and  cyanosis,  the  cold 
extremities  covered  Avith  clammy  sweat,  and  the  small  pulse — all 
these  give  rise  to  a  suspicion  of  the  true  condition,  which  is  either 

*  A.  Lesser.     Atlas  der  gerichtlichen  Medicin.     Berlin,  Hirschwald,  1884. 


TOXIC  GASTRITIS.  311 

verified  by  tlie  patient's  statements  or  by  examining  the  vomited  mat- 
ter. These  acute  poisonings,  if  not  fatal,  always  leave  behind  a  long 
illness  and  all  the  symptoms  of  severe  disturbance  of  the  functions 
of  the  stomach  ;  these  disturbances  are  jDartly  caused  directly  by  the 
profound  changes  in  the  coats  of  the  stomach,  above  all  in  the 
glandular  layer,  and  their  possible  ulceration,  partly  by  the  results  of 
cicatrization.  In  these  cases  the  mucosa  and  submucosa  may  also 
be  cast  off  in  shreds  ;  in  the  patient  observed  by  Laboulbene,  a 
piece  of  membrane  over  twice  the  size  of  the  palm  of  the  hand  was 
vomited  fifteen  days  after  swallowing  sulphuric  acid.  In  the  lecture 
on  chronic  gastritis  I  shall  consider  the  other  group  of  chronic 
poisoning. 

The  discussion  of  the  diagnosis  and  treatment  of  the  individual 
varieties  of  acute  poisoning  lies  beyond  my  province.  Yet  I  may 
be  permitted  to  make  the  general  remark  that  the  stomach  should 
be  immediately  emptied  with  the  tube  in  all  cases  which  are  not  due 
to  caustic  substances,  as  can  always  be  ascertained  by  inspecting  the 
rnouth  and  pharynx.  I  decidedly  prefer  this  to  the  administration 
of  emetics,  which  always  require  some  time  for  their  action,  and 
which,  especially  in  comatose  persons,  are  by  no  means  rehable. 
"We  can  cleanse  the  stomach  much  more  thoroughly  by  repeated 
siphonage  than  by  means  of  an  emetic,  and  we  can  always  introduce 
the  tube,  even  in  deep  coma ;  a  piece  of  gas-tubing,  which  can  be 
found  almost  everywhere  at  the  present  time,  can  readily  be  impro- 
vised, as  I  have  already  announced  in  1875,"^  in  my  report  of  a  case 
of  poisoning  w-itli  oil  of  mirbane  (nitrobenzol) ;  according  to  my 
experience,  the  only  difiiculty  will  be  to  rapidly  make  a  funnel 
through  wdiich  water  may  be  ]30ured  into  the  tube.  I  have  even 
gotten  along  with  a  medicine-bottle  by  knocking  out  the  bottom 
and  slipping  the  tube  over  the  neck.  We  can  proceed  to  the  real 
treatment  after  the  stomach  has  been  thoroughly  washed  out.  It  is 
self-evident  that  the  tube  must  not  be  used  where  there  is  danger 
of  perforation  from  the  swallowing  of  caustic  substances ;  here  we 
must  give  neutralizing  substances  in  solution.     Even  in  poisoning 


*  Ewald.     Zwei   Falle   von   Nitrobenzolvergiftung.      Berl.   klin.   Woehenschr., 
1875,  S.  3. 


312  DISEASES  OP  THE   STOMACH. 

by  acids  tlie  introduction  of  the  tube  will  seldom  be  necessary,  since 
the  unabsorbed  portion  of  the  acid  may  be  neutralized  by  means  of 
calcined  magnesia  suspended  in  water  (about  100  grammes  [  ^  iij] 
of  magnesia  to  500  c.  c.  [a  pint]  of  water),  which  forms  harmless 
compounds  with  hydrochloric,  sulphuric,  and  nitric  acids  and  an 
insoluble  salt  with  oxalic  acid.  But  in  addition  we  must  always 
give  alkalies,  preferably  very  soluble  sodium  salts,  in  order  to  pre- 
vent the  impoverishment  of  the  blood  in  these  inetals.  The  caustic 
alkalies  can  be  neutralized  with  solutions  of  tartaric  acid  (1  to  5  per 
cent),  vinegar,  or  lemon-juice. 


LECTUEE  YIIL 

CHRONIC    GLANDULAR   GASTRITIS — CHRONIC    CATARRH    OF   THE    STOMACH 
ATROPHY    OF    THE    STOMACH. 

Gentlemen  :  lu  tlie  course  of  time  chronic  glandular  gastritis 
lias  received  a  variety  of  names :  chronic  catarrh  of  the  stomach, 
habitual  dyspepsia,  indigestion,  atony  of  the  stomach,  status  gastri- 
cus,  bradypepsia  [/3paSu?,  slow  ;  TreTrrw,  to  digest],  aj)epsia,  etc.  This 
abundance  of  names  shows  that  different  processes  have  been  groujDed 
together  under  the  above  designations.  Thus  Copeland  includes 
under  dyspepsia  a  clinical  picture  which  is  evidently  that  of  gastric 
ulcer,  Todd '"  distinguishes  idiopathic  and  deuteropathic  dyspepsia, 
and  subdivides  the  former  into  functional  and  organic  varieties  and 
the  latter  into  sympathetic  and  symptomatic  ;  besides  these  he  recog- 
nizes atonic,  inflammatory,  irritable,  and  f  olhcular  gastric  dysj)epsia. 
Ross  f  has  three  great  groups  of  dyspepsias,  namely  :  (a)  inflamma- 
tory, (b)  functional,  (c)  organic ;  these  he  classifies  again  into  no 
less  than  nine  subdivisions. 

If  we  disregard  Broussais's  well-known  description  of  gastroente- 
rite,  which  for  a  long  time  exerted  a  powerful  influence  on  the  con- 
ception of  diseases  of  the  stomach  among  the  French  ;  even  to  this 
day  in  all  French  text-books,  we  find  that  dyspepsia  embraces  a 
large  chapter.  To  be  sure,  Damaschino  says,  "Za  dyspepsie  or' est 
pas  une  entite  morhide^''  \  yet  dyspepsia  is  discussed  in  very  broad 
terms,  and  we  find  dyspepsie  flatulente  acide,  essentielle,  etc.  ;  why, 
even  a  special  ^^  dyspepsie  des  liguides''^  is  spoken  of  by  Chomel ! 


*  Todd.      Cyclopaedia  of    Practical   Medicine,   article  Indigestion.      London, 
1833. 

J.  Ross.     Practical  Remarks  on  the  Treatment  of  the  Various  Forms  of  Dys- 
pepsia.    Edinburgh  Medical  Journal,  September,  1855. 

X  F.  Damaschino.    Maladies  des  voies  digestives.     Paris,  1880. 

(313) 


314  DISEASES  OP  THE  STOMACH. 

Germain  See,*  wlio  distinctly  describes  dyspepsia  as  an  "  oiJeration 
chimique  defecteuse^''  still  clings  to  a  purely  symptomatic  classifica- 
tion, and  divides  dyspepsias  into  those  with  changes  in  the  chemical 
functions  and  those  with  mechanical  disturbances.  This  is  about 
as  scientific  as  it  would  be  to  write  a  cha]3ter  on  dropsies,  although 
we  had  long  ago  advanced  from  a  symptomatic  to  an  anatomical 
classification. 

The  Germans  were  the  first  to  destroy  this  conception  of  dyspep- 
sia as  a  disease  and  to  recognize  it  as  only  a  pathological  condition ; 
therefore  Lebert  properly  excluded  the  chapter  on  dyspepsia  from 
his  treatise  on  the  diseases  of  the  stomach.  In  fact,  such  terms  as 
dyspepsia,  indigestion,  etc.,  are  merely  descriptive  of  a  functional 
disturbance  but  not  of  a  distinct  disease ;  and  hence  to-day  we  ought 
not  to  find  a  physician  who  considers  a  disturbance  of  digestion  as 
a  separate  disease. 

In  making  a  historical  review  of  this  chapter  in  the  works  of 
the  writers  in  this  field  we  find  that  its  extent  gradually  becomes 
smaller — in  other  words,  that  distinct  clinical  types  have  been  suc- 
cessively separated  from  this  large  group.  Thus,  to  give  only  two 
examples,  irritable  and  atonic  dyspepsias  are  now  included  under  the 
gastric  neuroses,  and  we  may  equally  well  class  some  of  the  cases 
described  by  the  older  writers  as  pyrosis  or  heart-burn  under  what 
we  now  recognize  as  acid  hypersecretion. 

I  shall  revert  to  this  topic  while  considering  the  conditions  of 
hyperacidity  which  I  classify  among  the  neuroses  of  the  stomach.  I 
will  merely  say  here  that  of  necessity  we  must  diffei^entiate  between  a 
catarrhal  (that  is,  a  chronic  infiammatory)  condition  of  the  glandular 
coat  of  the  stomach  and  the  nervous  affections  of  the  same,  be  the 
irritation  direct  or  indirect.  The  inflammatory  processes  are  always 
attended  by  a  lessening  of  the  glandular  secretion — i.  e.,  of  hydro- 
chloric acid  and  pepsin ;  and  instead  there  is  produced  a  more  or 
less  alkaline  transudate.  The  sum  of  these  two  factors  will  give  the 
absolute  acidity  or  alkalinity  of  the  stomach-contents  as  produced 
by  the  irritation  of  the  ingesta.    But  the  degree  of  acidity  is  always 


*  Germain  See.     Du  regime  alimentaire.     Paris,  1887.     Des  dyspepsies  gastro- 
intestinales.     Paris,  1883. 


PATHOLOGY  OF  CHRONIC   GASTRITIS.  315 

lessened,  and  it  is  tlierefore  a  distinct  contradiction  of  tlie  patho- 
logical meaning  of  the  term  inflammation,  and  especially  of  chronic 
catarrhal  processes,  to  speak  of  an  "  acid  catarrh,"  as  has  lieen  done 
up  to  recent  times,  in  absolute  violation  of  fundamental  medical 
principles. 

It  is  entirely  different,  however,  with  the  coexisting  production 
of  mucus,  which,  as  in  other  glands — the  submaxillary  gland,  for 
instance— does  not  go  hand  in  hand  with  the  formation  of  the  spe- 
cific secretion.  The  longer  the  stimulation  lasts  the  smaller  tlie 
percentage  of  the  organic  constituents  of  the  saliva  will  be  than  the 
inorganic,  and  probably  (although  this  is  not  yet  absolutely  known) 
the  amount  of  mucus  and  ptyalin  will  stand  not  in  the  same  but  in 
the  reverse  proportion.*  Analogous  to  this,  the  secretion  of  mucus 
in  the  stomach  may  be  very  abundant,  and  yet  the  gastric  juice  rnay 
be  absolutely  wanting  ;  such,  indeed,  is  often  the  case.  But  all  those 
conditions  which  are  accompanied  by  an  increased  secretion  of  gas- 
tric juice  must  be  classified  among  the  neuroses  of  the  stomach, 
whether  it  is  only  an  abnormal  reaction  to  a  normal  physiological 
stimulation— i.  e.,  occurring  only  during  digestion — or  whether  a 
continual  irritation  keeps  up  a  constant  secretion  of  the  glands. 
These  are  the  conditions  which  we  now  call  hyperacidity  and 
hypersecretion.  In  accordance  with  these  views,  I  shall  de- 
scribe these  conditions  among  the  nervous  disturbances  of  the 
stomach. 

Pathology. — The  anatomical  features  are  allied  to  the  conditions 
described  under  acute  gastritis.  For  the  greater  part  the  mucous 
membrane  has  a  yellowish-gray  or  slate-gray  color,  with  insular,  vas- 
cular, deeply  injected  areas  of  a  scarlet  or  brownish-red  color  ;  it  is 
usually  thickened,  on  an  average  one  or  two  millimetres  [-^-^  to  -^^ 
of  an  inch],  and  covered  with  a  delicate  but  firmly  adherent  layer  of 
mucus  ;  in  many  places  it  is  elevated  above  the  tense  submucosa, 
because  at  these  places  it  has  grown  more  rapidly  than  the  latter,  and 
forms  papillary  projections,  giving  rise  to  the  so-called  Stat  mame- 
lonee,  a  term  which  at  all  events  is  applied  by  some  authors,  not 
to  this  condition  but  to  the  polypoid  degeneration  of  the  mucous 

*  Vide  Ewald.     Klinik,  etc.,  I.  Theil,  3.  Auflage,  S.  47  and  50  et  seq. 


316  DISEASES  OF  THE  STOMACH. 

membrane.*  The  portion  of  the  stomach  usually  involved  is  the 
pylorus,  but  it  may  extend  to  the  fundus  and  even  the  entire  mu- 
cous membrane.  The  submucosa  and  muscularis  may  also  be  thick- 
ened, and  the  latter  especially  at  the  pylorus  may  cause  hypertrophy 
with  consecutive  stenosis.  To  this  condition  of  well-marked  hyper- 
trophy Brinton  has  applied  the  name  of  cirrhosis  of  the  stomach, 
while  the  French  writers  f  call  it  hyj)ertrophic  sclerosis  of  the  sub- 
mucosa and  muscularis. 

The  minicte  anatomy  of  tlie  process  is  that  of  a  parenchymatous 
and  interstitial  inflammation.  The  glandular  cells  are  partly  de- 
stroyed, partly  granular,  and  partly  shriveled  up ;  differentiation 
between  the  principal  {Raupizellen)  and  the  parietal  cells  {Belegzel- 
len)  is  impossible ;  in  many  places,  especially  in  the  pyloric  region, 
the  ducts  have  lost  their  regular  order  of  lying  alongside  of  one 
another,  and  show  an  atypical,  manifold  ramification  like  glove- 
fingers.  Isolated  glands  become  se^Darated  at  the  fundus  and  appear 
at  the  border  of  the  submucosa  as  cysts,  which  are  either  empty, 
with  a  smooth  lining  membrane,  or  are  filled  with  the  remains  of 
glistening  hyaline  cuboidal  epithelium.  There  is  an  abundant  small- 
celled  infiltration  which  is  especially  marked  near  the  surface  of  the 
mucous  membrane ;  the  cells  lie  between  the  glands,  and  in  places 
push  their  ducts  far  apart.  In  the  hyperplastic  form  we  see  j)ro- 
cesses  of  connective  tissue  which  proceed  upward  between  the  glands 
from  the  submucosa  like  the  branches  of  a  tree.  The  free  surface 
of  the  glandular  layer  is  covered  with  a  film  of  mucus  inclosing 
many  leucocytes  and  nuclei.  The  superficial  layer  of  the  epithelium 
of  the  mucosa  is  loosened,  and  can  be  separated  in  adherent  shreds 
Avliich  may  sometimes  be  found  in  the  wash-water  after  lavage  of 
the  stomach.  In  the  accompanying  drawing  (Fig.  26)  one  can 
readily  see  the  mouths  of  the  glandular  ducts  and  the  surrounding 
epithelium.  The  epithelial  cells  of  the  Vorraum  [the  short,  tunnel- 
like entrance  to  the  cavity  of  a  peptic  gland]  is  for  the  greater  part 
filled  with  a  pale  mucous  mass  which  projects  sharply  against  the 

*  Orth.     Loc.  cit.,  p.  709. 

•|- Hanot  et  Gombauldt.  Arch.de  physiol.,  ix,  p.  412.— Dubujadoiix.  Gazette 
hebdom.,  1883,  p.  198. — Kahlden.  Ueber  chronische  sclerosirende  Gastritis.  Cen- 
tralblatt  f  lir  klin.  Med.,  1887,  No.  16. 


PATHOLOGY  OF  CHRONIC  GASTRITIS.  317 

lumen  without  any  inclosing  membrane,  as  described  by  Kupffer  * 
in  the  normal  stomach.     I  have  been  able  to  study  this  and  the  fol- 


FiG.  26. — Mrs.  St.,  September  27, 1887.  From  a  pale,  reddish  shred,  the  size  of  a  grain  of  sand, 
which  was  found  between  some  pieces  of  mucus  in  the  wash-water  after  lavage  of  the 
empty  stomach. 

lowing  conditions  in  specimens  which  were  obtained  immediately 
after  death,  or  from  living  persons  after  resection  of  the  jjylorus. 
In  the  condition  (to  be  described  presently)  of  mucous  catarrh  this 
mucoid  degeneration  may  be  observed  to  extend  down  to  the  base 
of  the  glands,  so  that  in  place  of  the  ordinary  principal  and  parietal 
cells  we  only  find  cells  in  the  most  varied  stages  of  mucoid  degen- 
eration. This  condition  is  especially  marked  in  the  pyloric  region. 
Isolated  cells  may  be  found  which  are  still  intact,  the  mucus  filling 
only  a  small  part  of  them,  while  the  rest  of  the  cell  is  occupied  by 
granular  protoplasm  and  a  large  nucleus.  In  others  the  mucus  occu- 
pies the  greater  part  of  the  cells  and  crowds  the  protoplasm  and  the 
flattenpd  nucleus  against  its  base.  In  still  others  the  cell  membrane 
has  ruptured  and  the  mucus  has  escaped  into  the  lumen  of  the  duct 
of  the  gland,  where  it  has  been  precipitated  in  streaks  by  the  alcohol. 
This  gives  rise  to  very  delicate  figures,  which  resemble  a  row  of 
horseshoes  with  their  openings  toward  the  lumen  of  the  gland. 
Fig.  27  represents  a  highly  magnified  cross-section  of  a  glandular 
duct ;  the  section  has  passed  obliquely  through  the  duct  just  below 
the  so-called  neck  of  the  gland.  For  further  details  see  the  explana- 
tion appended  to  the  figure.     That  this  is  really  mucus  and  not  the 


*  Kupffer.     Epithel  und  Driisen   des  menschlichen  Magens.    Miinchen,    1883. 
Tafel  I. 


318 


DISEASES   OP   THE  STOMACH. 


isolated  formation  of  vacuoles,  as  described  by  Stolir  and  Saclis,  is 
easily  proved  by  tlie  reaction  with  acetic  acid  and  tlie  grayish,  color 
with  hsematoxylin  ;  yet,  I  re23eat,  these  features  are  only  found  where 
the  mucous  membrane  has  been  placed  in  alcohol  while  still  warm ; 
in  older  tissues  I  have  never  met  them.  Thus  there  is  a  mucoid  de- 
generation of  the  protoplasm  of  the  cells,  which  extends  deep  down 
into  the  fundus  of  the  gland.  Whether  these  changes  may  retro- 
grade, or  whether  they  are 
permanent,  I  can  not  yet  de- 
cide from  the  specimens  which 
I  have  at  present. 

As  the  disease  advances, 
chronic  gastritis  finally  causes 
retrogressive  changes  in  nu- 
trition, which  are  at  first  man- 
ifested in  a  progressive  fatty 
degeneration  of  the  glandular 
cells,  and  which  finally  cause 
complete  atrophy  of  the  mucous 
membrane,  a  condition  to  which 
Lewy  ^  has  recently  called  es- 
pecial attention.  This  has  led 
to  further  investigation  on  this 
subject,  although  it  had  al- 
ready been  carefully  studied 
and  illustrated  by  Fenwick  ;  f 
yet  these  pictures  are  very 
incomplete  according  to  our 
present  notions.  Freund  X  has 
also  described  this  condition 
in   a  monogi-ajDh,  rich  in  his- 


Fio.  27 — The  preparation  from  ■\^'hioh  this  sec- 
tion was  made  was  a  piece  of  mucous  mem- 
brane from  the  peripheiy  of  a  resected  pyloric 
carcinoma  ;  the  tissue  was  at  once  imbedded 
in  alcohol  while  still  warm.  Hardening  in 
alcohol ;  staining  by  Heidenhain's  method 
of  htemotoxylin  and  chromate  of  potassium. 
The  section  shows  the  various  stages  of  mu- 
coid degeneration  of  the  epithelial  cells,  and 
the  crowding  of  the  nuclei  toward  the  base 
of  the  cell.  Some  of  the  mucus  has  reached 
the  lumen  of  the  duet  of  the  gland  by  rup-r 
ture  of  the  cell  membrane,  and  has  been  pre- 
cipitated there  in  streaks  by  the  alcohol. 


*  B.  Lewy.  Chronische  Gastritis  mit  Atrophie  cler  Mucosa.  Ziegler's  Beitrage, 
Heft  1,  1886. — Ewald.  Ein  Fall  von  Atroijhie  der  Magenschleimhaut.  Beii.  klin. 
Woehenschr.,  1886. 

f  L.  Fenwick.     On  Atrophy  of  the  Stomach.     London,  1880. 

X  W.  A.  Freund.  Ueber  den  etat  mamelonne  und  die  Granularentartung  der 
Magenschleimhaut.    Breslau,  1863. 


PATHOLOGY   OF   CHRONIC   GASTRITIS, 


319 


torical  data,  under  tlie  name  of  granular  degeneration  of  the 
mucous  membrane  of  the  stomach.  These  changes,  if  a  large  area, 
or  especially  the   entire   surface,  of  the  mucous  membrane  be  in- 


FiG.  28. — From  a  case  of  anadenia  of  the  mucosa,  witli  accompanying  dilatation  of  the 
stomach.  Instead  of  the  mucosa  we  find  only  round  cells,  relatively  few  in  number, 
which  still  barely  indicate  the  normal  villus-like  arrangement.  The  muscularis  mu- 
cosae is  much  broader ;  the  submucosa  is  stretched  out,  and  contains  markedly  dilated 
blood-vessels  filled  with  blood-corpuscles.  The  muscularis,  which  is  not  represented  in 
the  drawing,  presented  a  peculiar  formation  of  spaces  between  the  individual  bundles 
of  muscle-fibers,  causing  it  to  look  like  a  network  of  cavities.     (Camera  lucida.) 


volved,  must  finally  lead  to  a  total  destruction  of   the   secreting 
parenchyma  with  all  its  consequences. 


320  DISEASES  OF  THE   STOMACH. 

The  process  may  advance  in  two  different  ways :  '^'  1.  In  the  one 
form,  in  addition  to  the  above-described  degeneration  of  the  gland- 
ular cells,  and  a  small-celled  infiltration  of  the  interglandular  con- 
nective tissue,  there  is  a  progressive  destruction  of  the  glandular 
parenchyma,  so  that  finally,  as  may  be  seen  in  Fig.  28,  nothing  is 
left  but  a  layer  (whose  thickness  is  much  less  than  that  of  the  nor- 
mal mucosa)  of  small  round  cells,  between  which  isolated  remnants 
of  the  former  parenchyma  may  here  and  there  be  found. 

Toward  the  cavity  of  the  stomach,  vvdiat  was  formerly  the  gland- 
ular layer  is  limited  by  numerous  villi  infiltrated  with  many  round 
cells.  Toward  the  submucosa — i.  e.,  in  tlie  deeper  layers  of  the  mu- 
cous membrane — may  be  found  remnants  of  glandular  ducts  running 
obliquely ;  these  are  still  in  the  earlier  stages  of  the  process,  and 
some  of  them  have  been  converted  into  larger  or  smaller  cysts.  The 
latter  fact  proves  that  the  process  has  progressed  from  above  down- 
ward, and  has  first  obliterated  the  orifices  of  the  ducts.  Later,  even 
these  remnants  of  the  gland'^^  disappear.  The  muscularis  mucosa  is 
much  thickened ;  the  submucosa  becomes  wider,  and  is  drawn  out 
into  a  network,  while  its  vessels  are  widely  dilated  without  showing 
any  marked  changes  in  their  walls.  A  peculiar  widening  of  the 
space  between  the  muscle  bundles  is  very  noticeable  in  the  muscu- 
laris. The  organ  in  toto  is  enlarged  ;  its  walls  appear  thinned  and 
brightly  transparent  in  areas  or  throughout  its  entire  extent.  The 
whole  process  seems  to  be  a  parenchymatous  one  which  has  extended 
from  the  surface  downward. 

2.  The  other  form  is  characterized  by  a  marked  activity  of  the 
interstitial  connective  tissue,  and  leads  to  its  hypertrophic  prolifera- 
tion, which  proceeds  from  tlie  base  of  the  glands  upward  toward  the 
lumen  (Fig.  29). 

The  few  fibers  which  are  normally  found  above  the  muscularis 
mucosae  are  thickened  ;  ascending  and  branching  like  a  tree  between 
the  glands,  they  surround  them  and  cut  them  off.     Yet,  unlike  the 


*  The  description  of  these  conditions,  based  upon  specimens  which  T  prepared 
with  Dr.  George  Meyer,  was  first  given  by  me  at  the  meeting  of  the  Berliner  med. 
Gesellschaft  on  November  14,  1888.— Berl.  klin.  Wochenschr.,  1888,  No.  49.— [See 
also  G.  Meyer.  Zur  Kenntniss  der  so-genannten  "  Magenatrophie."  Zeitschr.  fiir 
klin.  Med.,"  Bd.  xvi,  S.  366.— Tr.] 


PATHOLOGY   OF   CHRONIC   GASTRITIS. 


321 


first  form,  no  cysts  are  formed,  since  the  parenchymatous  cells  hav- 
ing been  deprived  of  their  nutrition  undergo  atrophy ;  so  that  finally, 


Fig.  29. — From  a  case  of  phthisis  ventriculi,  with  cirrhotic  atrophy.  Broad  bands  of  con- 
nective tissue  ascend  from  the  submucosa  (situated  to  the  right  in  the  figure)  upward 
between  the  glandular  tubules,  embrace  them  and  cut  them  off,  thereby  causing  the 
destruction  of  the  parenchyma.  In  many  places  are  to  be  seen  numerous  round  cells, 
which  surround  the  base  of  the  glands,  and  also  lie  in  the  meshes  of  the  connective 
tissue.  Toward  the  free  surface  of  the  mucous  membrane  is  a  small-celled  infiltration. 
The  muscularis  mucosse  is  gone.  The  submucosa  has  been  converted  into  a  tense 
fibrous  mass  of  connective  tissue,  in  which  a  few  isolated  remnants  of  ruptured  glands 
may  be  found.     (Camera  lucida.) 

as  is  shown  in  Fig.  30,  there  remains  only  a  meshwork  with  large 
interstices  whose  fibers  run  parallel  to  and  terminate  smoothly  at 
the  surface.  Isolated  remnants  of  ducts  and  cells  may  be  found 
here  and  there  in  the  form  of  hyaline  inclosures.  The  muscularis 
mucosae  disappears  entirely,  the  submucosa  is  traversed  by  bands  of 
connective-tissue  fibers,  but  the  muscularis  is  apparently  unaltered. 
The  organ  is  not  alone  not  enlarged  in  toto,  but  at  times,  as  in  a 
case  reported  by  ]^othnagel,*  may  be  small  and  cirrhotic.     I  have 


*  Nothnagel.  Cirrhotische  Verkleinerung  des  Magens  und  Schwund  der  Lab- 
driisen  unter  dem  klinischen  Bild  der  pernici5sen  Anamie.  Deutsch.  Archiv  fur 
Idin.  Med.,  Bd.  24,  S.  53. 


322 


DISEASES   OP  THE  STOMACH, 


examined  such  a  stomach,  the  capacity  of  which  was  only  180  c.  c. 
[f  §  vj].  Tlie  membrane  which  has  taken  the  place  of  the  mucous 
membrane  is  macroscopically  smooth  and  white,  gray,  or  slate-col- 
ored. In  such  cases  the  sclerotic  atrophy  involves  the  pyloric  region 
especially,  while  the  thinning  of  the  walls  of  the  stomach  occurs  in 
irregular  areas,  especially  at  the  fundus,  or  it  may  involve  the  entire 
organ. 

In  either  form  it  is  a  severe,  irreparable  process  which  specially 
Involves  the  glandular  layer  of  the  stomach,  and  which  is  character- 


FiG.  30. — Total  atrophic  sclerosis  of  tlie  mucous  membrane,  which  has  been  converted 
into  a  long,  stretched-out  portion  of  connective  tissue,  with  isolated  round  cells,  and 
hyaline  remnants  of  former  glandular  tissues.  Toward  the  free  border  of  what  was 
formerly  the  mucous  membrane  (to  the  left  of  the  figure)  the  closer  packing  of  the 
fibrous  bands  has  formed  a  kind  of  limiting  membrane.  The  muscularis  mucosae  has 
disappeared,  the  submucosa  is  thinned,  and  consists  of  undulating  bands  of  connective 
tissue.     Cystic  cavities  may  be  seen  very  close  to  the  free  border  of  the  membrane. 


ized  b}^  a  complete  disappearance  of  the  secreting  parenchyma.  I 
therefore  fully  agree  with  Dr.  George  Meyer,  who  wishes  to  abolish 
the  name  of  atropliy  of  the  stomachy  which  conveys  a  false  idea  of 
this  process,  and  proposes  as  a  substitute  phthisis  ventriciili,  gas- 
trio  phthisis  {Magenphthise).  As  an  amendment  I  would  suggest 
the  name  Anadenie  des  Magens,  because  the  lesion  causes  a  total 
destruction  of  the  secreting  parenchyma.  It  is  hardly  necessary  to 
explain  that  such  terms  as  catarrhus  atrophicans  or  atrophiciis  are 
ridiculous. 


POLYPI   OP  THE   STOMACH,  323 

So  much  for  these  final  stages  of  chronic  gastroadenitis. 

Another  change  arises  from  the  villous  outgrowths  from  between 
the  small  depressions  in  the  gastric  mucous  membrane  ;  this  gives 
rise  to  \\iq  jpolypoid  outgrowths  [Polypi]  from  it,  usually  the  size  of 
a  milium  {Ilirsekorvi)  to  a  pea,  and  arranged  alongside  of  one  an- 
other in  large  numbers,  although  at  times  thej  may  assume  larger 
dimensions.  Cruveilhier  has  a  drawing  of  a  specimen  in  which  the 
polypi  hang  down  from  the  mucous  membrane  like  the  teats  of  a 
young  bitch.  Ebstein  *  has  studied  their  structure  very  carefully, 
and  divides  them  into  the  pedunculated  and  the  non-pedunculated  ; 
those  occurring  in  groups  and  those  wdiich  are  isolated  ;  those  with  a 
smooth  and  those  with  a  polypoid  mucous  covering.  In  the  affected 
areas  the  connective  tissue  between  the  glands  is  always  increased 
and  forces  them  asunder.  The  mucous  membrane  and  submucosa 
are  thickened  in  larger  areas.  In  a  case  of  Lemaitre,f  carcinoma 
and  polypus  were  observed  together ;  amyloid  degeneration  of  the 
vessels  was  also  present. 

It  is  well  known  that  intestinal  polypi  may  not  infrequently  give 
rise  to  a  partial  or  complete  intussusception  of  the  intestine,  yet  a 
similar  condition  due  to  gastric  polypi  is  a  very  rare  occurrence. 
Such  a  case  of  intussusception  of  the  stomacli,  recently  described  by 
Chiari,:}:  tlierefore  deserves  esj^ecial  mention. 

The  patient  was  a  woman,  forty-four  years  old,  who  had  died  of  ma- 
rasmus. During-  life  a  tumor  was  felt  at  the  pylorus  ;  there  was  emacia- 
tion, accompanied  by  vomiting  of  blood ;  the  diagnosis  was  carcinoma  of 
the  pylorus  with  consecutive  dilatation  of  the  stomach.  At  the  autopsy 
a  funnel-shaped  depression  was  found  on  the  outer  wall  of  the  stomach  8 
centimetres  [3  inches]  from  the  pylorus,  and  into  which  the  middle  finger 
could  be  passed  6  centimetres  [2'4  inches]  toward  the  pylorus.  A  portion 
of  the  greater  omentum  had  been  drawn  into  this  rntussuGcepted  part  of 
the  stomach,  but  it  was  easily  replaced.  On  opening  the  stomach  it  was 
found  that  the  intussusception  was  due  to  thi^ee  large  polypi  like  cauli- 
flowers, situated  at  the  apex  of  the  prolapsed  portion  of  the  wall  of  the 
stomach;  together  they  formed  a  tumor  about  the  size  of  an  ^^g^  which 
extended  from  the  stomach  through  the  pylorus  into  the  duodenum,  to  a 

*  W.  Ebstein.  Die  polypose  Geschwlilste  des  Magens.  Keichert  und  Du  Bois' 
Arehiv.,  1864,  S.  94. 

\  Camus-Corignon.     Des  polypes  de  restomac.    These  de  Paris,  1883. 

X  A.  Chiari.  Ueber  Intussusception  am  Magen.  Prager  med.  Wochensehrift, 
1888,  No.  23. 

21 


324:  DISEASES  OP  THE  STOMACH, 

distance  of  2  centiinetres  [0'8  incli].  Although  this  did  not  cause  a  com- 
plete obstruction  of  the  pylorus,  since  the  index-finger  could  still  be  easily 
passed  through  it  into  the  duodenum  alongside  of  the  polypi,  yet  there 
must  have  been  a  serious  obstruction  to  the  passage  of  food  from  the 
stomach  into  the  intestines.  This  explained  what  was  found  during  life, 
and  justified  the  error  in  the  diagnosis. 

The  situation  of  polypi  close  to  tlie  pylorus  explains  why  tliey 
can  be  drawn  downward  by  the  strong  contractions  of  this  part  of 
the  stomach,  and  thus  cause  an  intussusception ;  the  latter  is  exceed- 
ingly rare,  as  stated  above,  when  the  polypi  are  situated  elsewhere. 

Etiology. — The  causes  of  chronic  gastritis  are  of  a  very  manifold 
nature.  First,  it  may  result  from  the  acute  and  subacute  forms, 
as  oft-repeated  attacks  frequently  lead  to  it,  especially  since  the 
causes  of  all  these  forms  may  be  the  same.  Such  irritants  can  act 
more  readily  when  the  mucous  membrane  has  been  altered  by 
changes  in  the  circulation  or  in  the  condition  of  the  blood,  the  mu- 
cous membrane  being  thus  rendered  more  sensitive  than  it  normally 
is.  Changes  in  the  circulation  may  be  produced  by  all  processes 
which  lead  to  venous  congestion  of  the  stomach — that  is,  the  affec- 
tions of  the  organs  of  the  portal  system,  especially  of  the  liver  and 
spleen  ;  also  diseases  of  the  heart,  and  tuberculosis. 

Among  the  conditions  which  probably  predispose  to  chronic 
gastritis  by  an  altered  condition  of  the  blood  are  chlorosis,  scrofula, 
anaemias  after  dysentery,  typhus  and  typhoid  fevers,  acute  exanthe- 
mata, pregnancy,  and  uterine  diseases ;  also  diabetes,  gout,  and 
chronic  affections  of  the  kidney. 

Finally,  chronic  gastritis  may  also  result  from  direct  local  irrita- 
tion, either  as  a  consequence  of  cicatrices  and  neoplasms  in  the  mu- 
cous membrane,  or  irritating  substances  which  are  brought  in  con- 
tact for  a  long  time  with  the  gastric  mucous  membrane,  either  from 
without  or  from  the  blood.  Among  the  former  is  the  swallowing 
of  large,  half-digested,  and  insufficiently  insalivated  morsels  of  food, 
which  irritate  the  gastric  mucosa,  either  directly  or  indirectly,  by 
predisposing  to  fermentation  of  the  stomach-contents.  Another 
source  of  irritation  from  without  may  be  putrefaction  in  the  mouth 
from  carious  teeth  or  inflammation  of  the  gums ;  these  putrid  prod- 
ucts are  swallowed  and  may  cause  inflammation  directly  or  indi- 


SYMPTOMS  OF  CHRONIC  GASTRITIS.  325 

recti  J.  To  tliis  category  also  belongs  tobacco-juice,  wliicli  fre- 
quently causes  first  a  subacute  and  tlien  a  chronic  inflammation  ; 
also  concentrated  alcoholic  beverages,  and  condiments  in  the  food 
which  may  cause  chronic  changes  after  prolonged  abuse ;  finally, 
true  toxic  substances  or  parasites  like  trichinae,  worms,  larvae,  etc. 
On  the  other  hand,  there  are  also  certain  toxic  substances  which  cir- 
culate in  the  blood  and  are  excreted  in  the  stomach — e.  g.,  urea  in 
chronic  renal  diseases,  and  the  products  of  intestinal  putrefaction  in 
constipation. 

The  most  important  of  these  etiological  factors  is  ahvays  the  en- 
trance of  the  above-mentioned  injurious  substances,  and  as  these  are 
usually  taken  of  the  sufferer's  own  free  will,  the  disease  may  be 
classified  among  those  in  which  the  patient's  indiscretions  play  a 
very  important  role.  But  as  most  persons  treat  their  stomaclis 
badly,  and  are  neither  able  to  resist  culinary  temptations  nor  take 
sufficient  precautions  at  the  beginning  of  their  trouble,  chronic 
"  stomach  catarrh  "  is  one  of  the  "  best-nourished  "  and  most  prev- 
alent diseases  in  the  world.  Indigestion  is  the  remorse  of  a  guilty 
stomach ! 

Clinical  History. — The  disease  presents  itself  in  two  clinical  forms, 
which,  when  fully  developed,  are  easily  differentiated :  Chronic 
sim/ple  gastritis  {catarrhus  gastricus  chronicus)  and  chronic  mucous 
gastritis  {catarrhus  gastricus  mucosus) ;  both  of  these  may  finally 
lead  to  atrophy  of  the  mucous  memhrane.  Although  the  symptoms 
of  these  different  conditions  have  long  been  known  and  described, 
yet  on  the  one  hand  they  have  not  been  described  as  independent 
diseases,  nor  on  the  other  hand  has  their  mutual  connection  been 
recognized.  Dr.  Boas,*  by  using  the  new  methods  of  examination, 
deserves  the  credit  of  having  differentiated  the  atrophic  from  the 
mucous  form,  even  though  he  goes  too  far  in  regarding  the  former 
as  an  independent  condition.  It  is  simply  the  last  stage  of  the 
latter.  But  there  are  many  transitional  stages  between  the  simple 
and  mucous  varieties,  so  that  a  sharp  distinction  between  the  two 
processes  is  sometimes  impossible. 


*  J.   Boas.     Zur    Symptomatologie   des   ehronischen   Magenkatarrhs   und   der 
Atrophie  der  Magensehleirahaut.     Miinch.  med.  Wochenschr.,  1887,  No.  42. 


326  DISEASES   OP   THE  STOMACH. 

In  the  initial  stages  tlie  subjective  symptoms  are  about  the  same 
in  the  different  forms,  namely,  those  of  difficult  digestion,  or  of 
chronic  dyspepsia ;  it  is  only  after  the  development  of  a  progressive 
phthisis  (atrophy)  of  the  gastric  mucous  membrane — and,  as  it  seems, 
only  after  it  has  been  established  for  a  long  time — that  the  cymp. 
toms  of  rapid  decline  of  the  organism  become  manifest.  The  dif- 
ferentiation really  depends  on  the  result  of  the  chemical  examina- 
tion of  the  stomach-contents. 

Let  us  first  consider  the  local  and  general  symptoms  which  are 
common  to  all.  The  patients  usually  complain  of  a  dry,  pasty,  or 
salty  taste  in  the  mouth,  which  is  also  communicated  to  the  food 
during  mastication.  There  is  nothing  characteristic  about  the 
tongue ;  it  is  seldom  clean  but  usually  coated,  either  entirely  or  at 
the  base,  where  the  reddened,  swollen  paj^illse  project  like  straw- 
berries, while  the  edges  bear  the  impressions  of  the  teeth  ;  the 
thick  fur  which  accompanies  carcinoma  [of  the  stomach]  is  usually 
absent.  The  tongues  of  delicate  anaemic  patients  have  a  more  uni- 
form transparent  coating,  giving  the  organ  a  bluish-white  color. 
Occasionally  aphthae  form  at  the  edges  and  cause  the  patient  much 
annoyance.  In  the  morning  the  coat  is  much  thicker  than  in  the 
evening,  because  the  movements  of  the  tongue  serve  to  keep  it 
clean  ;  if  some  teeth  are  missing,  we  notice  that  the  coating  is  thicker 
on  that  side,  although  this  is  not  always  to  be  explained  thus.  The 
lips  are  usually  dry  and  chapped.  Belching  is  very  frequent ;  the 
gas  is  either  odorless  or  has  an  offensive  sour  smell  and  disagreeably 
rancid  taste.  It  is  frequently  accompanied  by  the  regurgitation  of 
fluid  or  I'emnants  of  food  from  the  stomach,  having  a  very  sour  and 
disagreeable  taste ;  these  regurgitated  masses  often  impart  a  burn- 
ing and  scratching  sensation  along  the  oesophagus — heart-hum  {Sod- 
hrennen)  or  pyrosis,  the  ardor  'ventriculi  of  Hoffmann.  If  this 
sensation  is  limited  to  the  lower  section  of  the  oesophagus,  or  to  the 
cardia,  and  is  of  an  intense  character,  it  may  be  termed  cardialgia. 
Such  an  exact  distinction  between  pyrosis  and  cardialgia  is  usually 
impossible,  even  if  Cullen,  of  Scotland,  Ras  described,  under  the 
name  of  pyrosis,  a  peculiar  group  of  symptoms  of  Adolent  cardialgia 
occurring,  especially  among  the  Scotch  country  people,  paroxysmally 
in  the  morning  before  eating,  and  which  is  relieved  by  the  vomiting 


SYMPTOMS  OF  CHRONIC   GASTRITIS.  327 

of  a  watery  fluid.  On  the  other  hand,  a  difference  must  be  made 
between  cardialgia  and  gastralgia,  and  they  mnst  not  be  used  in- 
discriminately for  each  other,  as  is  done  by  the  older  writers.  The 
latter  is  a  diffuse  pain  in  the  stomach  ;  the  former  is  a  pain  limited, 
as  its  name  denotes,  to  about  the  situation  of  the  cardia,  at  the  line 
of  junction  between  the  body  of  the  sternum  and  the  ensiform  pro- 
cess at  the  level  of  the  sternal  attachment  of  the  seventh  rib.  But 
when  the  heart-burn  is  especially  pronounced,  whether  along  the 
entire  course  of  the  oesophagus  or  only  at  the  cardia,  or  whether 
only  sour  masses  are  regurgitated  into  the  mouth  without  causing 
any  marked  burning  sensation  in  the  oesophagus,  it  is  always  im- 
portant to  endeavor  to  ascertain  its  exact  nature,  and  to  distinguish 
sharply  between  the  sour  masses  Mdiose  acidity  is  due  to  the  prod- 
ucts of  fermentation  and  putrefaction  (acetic  acid,  fatty  acids,  lactic 
acid)  and  such  as  owe  their  taste  to  an  exaggeration  of  the  normal 
acidity  of  the  gastric  juice  (i.  e.,  to  a  hypersecretion  of  hydro- 
chloric acid),  and  finally  from  those  somewhat  paradoxical  cases  in 
which,  in  spite  of  the  symptoms  of  pyrosis,  as  shown  by  Mac- 
liaught,*  the  acidity  and  condition  of  the  stomach-contents  are  nor- 
mal. It  is  only  the  first  of  these  forms  (which  had  been  described 
by  Graves  as  long  ago  as  1823)  which  is  to  be  considered  as  belong- 
ing to  chronic  gastritis  ;  the  other  two  forms  are  to  be  classed  with 
the  neuroses  of  the  stomach.  In  the  latter  conditions  there  may 
sometimes  be  such  an  intolerance  toward  acids  that,  as  Talma  f  has 
observed,  the  administration  of  solutions  of  hydrochloric  acid  of 
normal  or  even  subnormal  acidity  may  produce  the  symptoms  of 
pyrosis  and  cardialgia  in  nervous  persons. 

Yomiting  is  of  very  irregular  occurrence ;  the  condition  of  the 
vomited  masses  depends  on  the  stage  of  the  disease,  so  that  the 
amount  of  digestive  and  putrefactive  products  contained  in  them 
varies  a  great  deal.  Nausea  and  trismus  usually  precede  it.  The 
appetite  is  either  slight  or  may  be  lacking  entirely  ;  yet  the  good  and 
bad  phases  alternate,  so  that  in  the  former  the  patients  often  easily 
commit  dietetic  errors  and  cause  fresh  irritation.     Many  patients  go 

*  MacNaught.    Med.  Chronicle  [Manchester],  January,  1885. 
f  Talma.    Ueber  Behandlung  von   Magenkrankheiten.     Zeitschrift  fur  klin. 
Med.,  Bd.  8,  S.  407. 


328  DISEASES  OP  THE  STOMACH. 

to  tlie  table  with  good  appetites,  but  the  first  few  morsels  satisfy 
their  cravings  ;  others  verify  the  saying,  "  L^a})])etit  vient  en  man- 
geantr  While  in  the  latter  there  is  just  enough  irritation  to  stimu- 
late the  glands  to  secretion,  in  the  former  it  is  too  much  for  the 
irritable  mucous  membrane,  and  may  check  the  secretion  by  causing 
an  abnormal  hypersemia.  Without  being  really  thirsty  most  patients 
desire  a  "  hearty  swallow,"  or  some  sour  drink,  and  demand  fluids, 
especially  while  eating.  Soon  after  eating  the  patients  feel  op- 
pressed and  bloated  :  they  do  not  complain  of  a  true  spontaneous 
pain  in  the  epigastrium ;  it  is  more  of  a  choking,  a  vague  sensation 
which  only  becomes  a  slight  pain  on  pressure  over  the  stomach ; 
true  gastralgise  do  not  belong  to  the  ordinary  symptoms,  and  their 
occurrence  should  always  lead  us  to  suspect  the  presence  of  other 
lesions.  The  patients  very  frequently  have  the  feeling  that  the  food 
remains  abnormally  long  in  the  stomach,  and  they  often  describe 
very  effectively  the  vain  efforts  of  the  oppressed  viscus  to  drive  the 
ino-esta  on  into  the  intestines. 

In  fact,  finally,  these  conditions  may  be  combined  with  weakness 
of  the  gastric  muscular  wall — atony  of  the  stomach — which  in  turn 
causes  a  lengthened  stay  of  the  food  in  the  stomach.  As  a  result, 
decomposition  takes  place  in  the  ingesta  ;  the  carbohydrates  ferment ; 
the  albuminoids  putrefy — a  condition  which  Escherich  has  called 
"  alkaline  fermentation."  This  produces  distention  of  the  stomach 
with  g^aS)  eructation  of  offensive  gases,  and  regurgitation  of  sour  and 
rancid  masses.  The  distention  of  the  stomach  in  turn  paralyzes  its 
muscular  fibers  and  causes  a  feeling  of  tension  and  pain ;  the  decom- 
posed or  insufficiently  digested  stomach-contents  irritate  the  intes- 
tines, and  the  conditions  thus  produced  are  reflected  back  to  the 
stomach,  and  thus  the  vicious  circle  which  is  present  in  all  affections 
of  the  stomacli  is  completed.  I  have  already  shown  how  these  con- 
ditions may  finally  lead  to  dilatation  or  a  true  gastrectasis  (pp.  130  et 
seq.) ;  here  I  wish  to  simply  add  that  these  decompositions  usually 
occur  at  night ;  in  the  morning  they  may  be  absent  or  only  very 
slight. 

Constipation  exists,  as  a  rule ;  exceptionally  the  evacuations  are 
regular ;  in  a  few  cases  diarrhoea  and  constipation  alternate ;  if 
hgemorrhoids  are  present,  as  frequently  happens,  the  movements  are 


SYMPTOMS  OF  CHRONIC   GASTRITIS.  329 

painful.  Tlie  stools  are  sometimes  light-colored,  sometimes  dark- 
green  ;  or  they  may  be  very  ofl'ensive  and  contain  undigested  food. 
The  patients  have  the  sensation  that  the  evacuations  are  incomplete, 
and  suffer  much  from  flatulence  and  rumbling  in  the  abdomen,  which 
is  sometimes  loud  enough  to  be  heard  at  a  distance.  Often,  instead 
of  true  fseces,  the  stools  are  watery  or  slimy,  as  a  result  of  the  irri- 
tation of  the  intestinal  mucous  membrane  by  hard  scybalse ;  for,  if 
tlie  rectum  of  these  patients  be  examined,  it  will  be  found  full  of 
hard  masses,  which  can  not  be  expelled  on  account  of  the  paresis  of 
the  muscular  fibeis  of  the  gut. 

The  urine  is  scanty,  deposits  urates  abundantly,  and  is  at  times 
alkaline  from  basic  salts.  Unfortunately,  as  yet  we  have  no  exact 
investigations  to  show  how  the  disturbances  of  the  metabolism  are 
manifested  through  the  kidneys,  although  in  connection  with  our 
recent  knowledge  of  the  formation  of  alkaloids  in  the  organism  this 
would  seem  to  be  a  very  promising  field  for  investigation. 

Among  the  general  symptoms  we  notice  a  diminution  of  mental 
activity,  disinclination  to  bodily  exertion,  languor  during  the  day, 
especially  after  meals,  headache  or  a  feeling  of  oppression  in  the 
head,  and  a  morose,  irritable  disposition.  The  patients  frequently 
complain  of  a  feeling  of  heaviness  in  every  limb,  cold  extremities, 
itching,  and  formication.  Sleep  is  deep  and  longer  than  usual,  but 
is  not  refreshing  and  is  disturbed  by  hideous  dreams.  Yawning  is 
frequent  and  is  accompanied  by  an  unpleasant  sensation  of  pucker- 
ing in  the  mouth  and  an  increased,  flow  of  saliva ;  the  patients 
"  hack  "  very  frequently  and  expectorate  tenacious  mucus  contain- 
ing dark  particles.  This  is  the  so-called  ''  stomach  cough  of  dyspep- 
tics," which  of  course  has  no  more  to  do  with  the  stomach  than  that 
the  pharyngeal  catarrh  which  causes  it  is  usually  due  to  the  same 
factors  as  the  gastritis — i.  e.,  abuse  of  irritating  substances,  especially 
alcoholic  beverages.*  At  all  events,  it  may  happen  that  the  already 
inflamed  pharyngeal  mucous  membrane  may  be  ii-ritated  by  the  re- 

.  *  The  existence  of  a  true  "  stomach  cough  "  has  not  yet  been  proved — that  is, 
a  reflex  act  starting  from  the  mucous  membrane  of  the  stomach  and  causing  acts  of 
coughing.  Such  eminent  authors  as  Naunyn,  Nothnagel,  and  Edleffsen  directly 
deny  it.  Recently  a  case  of  paroxysmal  coughing  proceeding  reflexly  from  the  gas- 
tric mucous  membrane  has  been  published  by  E.  Bull.  Deutseh.  Archiv  fur  klin. 
Med.,  Bd.  41,  S.  472. 


330  DISEASES  OP   THE  STOMACH. 

gurgitation  of  the  acid  stomach-contents  and  thus  may  cause  cough  re- 
flexes to  be  sent  out  from  the  crossing  of  the  oesophagus  and  bronchi. 
Such  "  coughs  "  usually  disappear  after  neutralizing  or  lessening  the 
acidity  of  the  stomach-contents. 

The  pulse  is  small  and  weak,  sometimes  intermittent,  and  this 
irregularity  of  the  heart  action  is  felt  by  the  patient  as  palpitation. 
Some  patients  have  a  certain  characteristic  odor  which  is  also  com- 
municated to  their  underwear,  and  with  each  exacerbation  this  odor 
becomes  stronger.  Evening  rises  of  temperature  may  also  be  ob- 
served in  this  disease,  and  have  indeed  required  antipyretic  treat- 
ment, and  have  even  been  mistaken  for  typhoid  fever  [or  ma- 
laria].* 

All  of  the  above  symptoms  will  not  be  found  in  all  cases  nor 
even  in  the  majority  of  them.  Sometimes  one,  sometimes  another 
symptom  will  predominate  and  characterize  the  clinical  picture. 
Thus  some  patients  complain  only  of  the  distention  of  the  abdomen 
and  marked  dyspnoea,  and  thus  we  have  the  group  of  symptoms 
described  as  dyspeptic  asthma  {asthma  dyspeptictim).  Others  are 
annoyed  especially  by  the  cough,  loss  of  appetite,  acid  regurgitation, 
choking  and  burning  sensation  in  the  abdomen.  In  still  others,  the 
irregular  heart  action,  palpitation,  irregular  and  intermittent  pulse 
are  especially  prominent  and  may  arouse  suspicions  of  organic  car- 
diac disease.  These  symptoms  occur  especially  during  digestion, 
are  complicated  by  pulsation  in  the  e^iigastrium,  but  are  less  marked 
when  the  stomach-contents  pass  into  the  intestines  or  when  the  ten- 
sion is  lessened  by  belching  up  gas.  A  variety  of  this  cardiac  dys- 
pepsia, which  had  already  been  described  by  Henoch,f  has  recently 
been  especially  studied  and  published  by  Rosenbach,:}:  under  the 
title  of  "  TJeber  einen  wahrscheinlich  auf  einer  Neurose  des  Yagus 
hestehenden  Syiniytoinencomplex "  ["  On  a  Group  of  Symptoms 
probably  due  to  a  Neurosis  of  the  Yagus  "] — (see  chapters  on  the 
gastric  neuroses).     But  common  to  all  patients  is  the  very  slight 

*  [On  the  other  hand,  cases  not  infrequently  occur  in  which  the  dyspeptic  symp- 
toms, gastralgia,  and  vague  fever  disappear  promptly  on  the  administration  of  anti- 
periodic  remedies. — Tr.] 

t  hoc.  cit.,  p.  391. 

X  0.  Rosenbach.  Neurose  des  Vagus  bei  Dyspepsie.  Deutsch.  med.  "Wochenschr., 
1879,  Nos.  42  and  43. 


SYMPTOMS  OF  CHRONIC  GASTRITIS.  331 

tenderness  on  pressure  or  spontaneous  pain  in  the  epigastrium  and 
tlie  chemical  changes  in  the  digestive  processes. 

Here  I  may  also  mention  that  peculiar  condition  first  described 
by  Trousseau  as  vertigo  gyrosa  or  vertigo  e  stomacho  laeso  {vertigo 
stomachalis),  gastric  vertigo,  and  also  discussed  at  about  the  same 
time  by  Briick,  of  Osnabriick,*  as  Schwindelangst  ("  vertigo-fear  "), 
mira  vertiginosa  •  this  subject  has  since  been  carefully  studied  by 
Blondeau,  Niemeyer,  von  Basch,  "Westphal,  Cordes,  Eyselein,  and 
others.  But  Trousseau  deserves  the  credit  of  having  first  directed 
attention  to  the  relation  of  these  attacks  of  vertigo  with  chronic 
catarrhal  gastritis.  They  occur  without  loss  of  consciousness,  begin 
usually  some  time  after  eating,  although  sometimes  they  may  le 
checked  by  taking  food,  but  can  not  be  produced  either  by  rapid 
circular  movements  or  by  inclining  the  head  forward,  or  similar 
motions.  The  attacks  pass  away  after  remaining  quiet  and  regu- 
lating the  diet,  but  are  usually  followed  by  severe  headaches.  Some- 
times these  attacks  assume  the  form  of  the  agoraphobia,  and  have 
been  described  as  such  by  the  writers  last  mentioned  above.  Here 
the  patients  experience  an  indefinable  terror ;  they  may  even  be 
unable  to  go  alone  over  large  open  fields,  places,  or  broad  streets, 
either  avoiding  crossing  such  places  entirely  or  seeking  company 
even  of  strangers.  Granting  that  these  conditions  actually  belong 
to  or  border  upon  the  mild  psychoses,  yet  they  must  not  be  re- 
garded as  neuroses  of  the  stomach  in  the  sense  that  there  is  a  dis- 
ease of  this  organ  due  directly  or  indirectly  to  the  nervous  system. 
On  the  other  hand,  they  must  be  considered  reflexes  from  an  organic 
disease  of  the  stomach  upon  the  brain,  and  are  thus  to  be  sharply 
differentiated  from  the  conditions  to  be  presently  described  as  nerv- 
ous dyspepsia.  We  may  accept  the  explanation  of  their  origin  pro- 
posed by  Mayer  and  Pribram  that  the  arterial  pressure  in  the  cere- 
bral vessels  is  raised  by  the  reflexes  from  the  walls  of  the  stomach, 
or  the  assumption  of  Bernstein  and  Asp  that  they  are  due  to  an  irri- 
tation of  the  splanchnic. 

The  following  cases  may  be  cited,  since  these  conditions  are  not 
common.     The  patients  were  middle-aged  men,  for  it  usually  occurs 

*  Briick.     "  Vom  Schwindel."    HiifelancVs  Journal,  Bd.  17,  St.  5. 


332  DISEASES  OP   THE  STOMACH. 

in  sucli  patients,  although  the  ages  of  the  54  cases  collected  by 
Cordes  *  vary  betAveen  nineteen  and  forty-seven  years.  Common  to 
all  of  them  is  the  chronic  catarrhal  gastritis,  and  the  disappearance 
of  the  agoraphobia  after  this  was  cured. 

The  first  case  was  a  captain,  who,  while  complaining  to  me  that  he 
suflPered  from  mild  local  gastric  troubles,  and  occasional  slight  headaches, 
said  that  for  some  time  he  had  also  experienced  real  terror  when  walking 
or  riding  over  large,  open  places  to  such  an  extent  that  he  was  unable  to 
cross  the  parade-ground  alone  ;  if  he  did  succeed  in  riding  over  it,  when 
half-way  across  he  was  seized  with  such  terror  that  he  had  to  dismount — 
and  that  then,  while  leading  his  horse  by  the  bridle,  he  could  proceed 
without  any  further  trouble. 

The  second  case  also  happened  to  be  a  military  ofiicer,  on  duty  at  the 
ministry  of  war,  who  said  that  he  had  the  greatest  fear  of  a  smooth  level 
area  on  which  there  was  no  resting-place  for  the  eye.  Thus  he  could  not 
go  alone  through  large,  empty  rooms  with  hard-wood  floors,  and  that  it 
was  especially  disagreeable  to  him  to  walk  on  the  smooth  asphalt  pave- 
ment, so  that  he  either  made  detours  or  sought  company. 

The  third  case  was  a  government  employe  who  had  to  pass  over  an 
open  square  every  day  to  reach  his  office  ;  at  first,  while  crossing  this,  a 
feeling  crept  over  him  that  it  was  impossible  to  reach  the  other  side,  and 
that  the  ground  shook  under  him.  If  he  attempted  to  force  his  way,  after 
a  few  stei3S  he  was  attacked  with  such  vertigo  that  he  feared  he  would 
fall,  and  had  to  give  up  the  attempt. 

In  all  these  cases  this  psychosis  disappeared  entirely  as  soon  as  the 
gastric  symptoms  were  cured  by  suitable  treatment. 

As  I  have  already  stated,  the  differences  between  these  two  or 
three  varieties  of  chronic  catarrhal  gastritis  are  manifested  not  so 
much  by  the  subjective  and  objective  symptoms  as  in  the  variations 
in  the  chemical  processes  of  the  stomach,  as  revealed  by  careful 
chemical  tests.  To  avoid  repetitions,  I  shall  consider  this  while 
speaking  of  the  diagnosis.  Here  I  simply  desire  to  add  a  few 
words  to  what  has  already  been  said  about  atony  of  the  stomach. 

The  conception  and  the  term  atony  have  been  used  so  long  in 
the  pathology  of  the  stomach  that  the  attempts  of  von  Pfungenf  to 
describe  a  new  disease  under  this  title  do  not  seem  to  me  to  be  jus- 
tifiable. If  by  the  term  atony  we  understand,  as  its  name  denotes, 
a  deficiency  in  the  muscular  tone,  and  as  a  result  an  insufiicient  mus- 
cular activity,  a  mechanical  or  muscular  insufficiency  of  the  stomach, 


*  Westphal's  Archiv,  Bd.  ill,  S.  521 ;  also  Bd.  v. 

f  R.  V.  Pfungen.     Ueber  Atonie  des  Magens.     Wien,  1887. 


ATONY   OF   STOMACH.  333 

then  it  is  not  proper  for  certain  writers  to  also  include  disturbances 
of  the  glandular  secretion.  Atony  arises  either  idiopathicallj  or  deu- 
teropathicallj,  primarily  or  secondarily,  as  we  prefer  to  express  it 
now.  Primary  atony  is,  in  my  opinion,  a  neurosis  and  is  always  a 
rarity.  Secondary  atony  is  associated  with  nearly  all  affections  which 
involve  larger  areas  of  the  gastric  mucous  membrane ;  in  fact,  we 
may  say  that  the  first  marked  objective  symptoms  are  usually  due  to 
the  atony,  since  before  the  tone  of  the  organ  is  lost  the  damage  done 
by  an  insufiicient  secretion  or  incomplete  absorption  is  compensated 
by  the  muscular  fibers  of  the  stomach — that  is,  the  chyme  is  still 
properly  expelled  into  the  intestines.  But  it  also  occurs  in  conditions 
of  general  debility  which  lead  to  torpor  and  insufiiciency  of  individ- 
ual organs  as  well  as  of  the  general  metabolism  ;  hence  it  is  especially 
frequently  observed  in  the  initial  stages  of  rickets  and  scrofula  in 
children  and  also  in  phthisis,  chlorosis,  etc.  The  large,  distended  ab- 
domens of  scrofulous  children  are  classical  proofs  of  this.  Here  there 
is  an  atony  of  the  stomach  and  intestines  which  leads  to  manifold  dis- 
turbances of  digestion  and  nutrition,  and  causes  the  dilatation  of  the 
stomach  which  occurs  sooner  or  later,  as  I  have  already  stated.  In 
these  cases  the  atony  is  never  a  primary  lesion,  but  is  always  the 
result  of  a  general  dyscrasia.  It  is  only  primary  in  so  far  as  other 
diseases  of  the  stomach  arise  from  it.  Therefore,  atony  of  the 
stomach  deserves  an  important  place,  as  was  first  shown  by  Rosen- 
bach  in  a  careful  analysis  entitled  "  Der  Mechanismus  und  die 
Diagnose  der  Mageninsufficiens,^^  and  still  more  completely  ap- 
plied in  every  direction  by  von  Pfungen  in  the  work  cited  above ; 
and  the  more  so,  because  the  primary  forms  with  their  mechanical 
changes  influence  the  chemical  and  other  functions  as  well  as  those 
of  motion. 

Hence,  in  all  severe  cases  of  chronic  gastritis  the  salol  test  shows 
a  delay  in  the  expulsion  of  the  chyme  into  the  intestines,  but  it  is 
normal  in  mild  cases.  On  the  other  hand,  this  also  explains  why,  as 
has  already  been  referrscl  tj,  dilated  stomachs  cause  no  subjective 
symptoms  as  long  as  the  muscular  power  of  the  stomach  is  able  to 
maintain  an  equilibrium  in  spite  of  the  increased  burden,  and  as 
long  as  the  salol  test  indicates  a  normal  expression  of  the  chyme.  I 
will  not  now  enter  into  an  irrelevant  discussion  to  which  the  latest 


334  DISEASES  OF  THE  STOMACH. 

investigations  have  led  as  to  whether  there  is  a  separate  disturbance 
of  the  peristalsis  of  the  f undal  or  pyloric  portions  of  the  stomach ;  the 
result  is  the  same  so  far  as  we  are  now  concerned,  but  I  will  consider 
this  in  greater  detail  when  speaking  of  atony  as  a  nervous  condition. 
For  in  the  j^resent  cases  the  atony  is  only  a  secondary  pathological 
process,  and  is  only  to  be  regarded  as  a  symptom  and  not  as  an  inde- 
pendent disease.  There  are  constitutional  reasons  why  it  appears 
early  in  some  and  later  in  others  ;  why  the  course  is  mild  or  severe, 
and  why  its  origin  may  even  be  traced  back  to  childhood  in  some 
cases  {vide  reports  of  Wiederhofer,  Kundrat,  Comby,  and  others). 
But  whether  the  atony  is  primary  or  secondary,  it  leads  in  all  cases 
to  a  relaxation  and  distention  or  even  a  dilatation  of  the  viscus 
which,  as  Poensgen  has  observed,  other  things  being  equal,  occurs 
the  more  readily  the  more  relaxed  the  anterior  abdominal  wall  is 
and  the  less  support  afforded  by  it  to  the  stomach. 

A  very  interesting  feature  is  the  final  stage  of  chronic  catarrhal 
gastritis  already  spoken  of  [page  318]  as  atrophy  of  the  mucous  mem- 
brane, or  better,  anadenia  [avd,  without ;  ahi^v,  gland]  of  the  stomach 
{Anadenie  des  Magens),  since  this  is  not  so  much  a  disturbance  of 
nutrition  which  spares  the  structure  of  the  tissue ;  it  is  rather  a  pro- 
cess which  causes  a  complete  destruction  of  the  glandular  paren- 
chyma, and  whose  gradual  development  may  be  designated  phthisis 
QnucoscB  /  it  has  also  been  improperly  called  gastric  phthisis. 

This  process  may  be  partial  or  complete ;  it  assumes  importance 
only  in  the  latter  case,  since  the  destruction  of  circumscribed  areas 
in  the  former  may  easily  be  compensated  by  the  rest  of  the  paren- 
chyma. According  to  the  anatomical  details  of  the  lesion  already 
given,  we  observe  a  progressive  loss  of  secreting  elements  which 
must  finally  lead  to  a  total  abolition  of  secretion  ;  and  with  this  the 
digestive  activity  of  the  stomach  is  gradually  and  irrevocably  de- 
stroyed. The  consequences  of  this  process  are  self-evident.  After  a 
longer  or  shorter  period,  marked  by  dyspeptic  complaints,  so  severe 
a  disturbance  of  the  nutrition  is  developed  that  the  patient  literally 
pines  away  "like  a  lamp  the  oil  of  which  has  not  been  replenished," 
and  finally  dies  of  marasmus.  At  all  events,  we  now  possess  sufficient 
clinical  data  to  show  that  the  intestines  may  act  vicariously  for  the 
stomach,  and  may  assume  the  entire  task  of  assimilation  of  the  nu- 


ANADENIA  OF  THE  STOMACH.  335 

trition.  But  this  seems  to  be  limited  to  a  definite  time,  wliicli 
varies  in  different  individuals ;  for  sooner  or  later  pathological  pro- 
cesses also  attack  the  intestine  and  abolish  its  activity,  either  on  ac- 
count of  the  extra  work  imposed  upon  it,  or  other  accidental  causes. 
Then  the  compensatory  action  of  the  intestines  suddenly  ceases,  and 
apparently  a  fresh  disease  breaks  out.  The  conditions  which  prevail 
here  can  not  be  different  than  in  other  viscera ;  at  least,  we  know  of 
no  associated  organs  with  vegetative  functions  which  ai-e  of  great 
importance  to  the  economy  where  one  could  replace  the  other  for 
an  indefinite  time.  Of  course,  we  know  that  it  can  be  done  for  a 
short  period,  but  not  beyond  that ;  it  is  true  of  the  lungs  as  well  as 
of  the  kidneys.  The  same  occurs  in  the  individual  sections  of  the 
digestive  tract,  and  just  as  it  is  impossible  to  nourish  a  person  indefi- 
nitely per  rectum,  so  the  stomach  can  not  permanently  lie  idle ;  for 
it  is  not  merely  a  place  for  digestion  and  disinfection,  but  it  is  also 
an  organ  of  vital  importance. 

During  the  period  of  compensation  the  general  condition  of  the 
patient  will  de23end  entirely  upon  the  extent  to  which  the  motor 
functions  of  the  stomach ^ — i.  e.,  its  ability  to  forward  its  contents  on 
into  the  intestines — are  preserved  ;  in  other  words,  whether  the  mus- 
cular fibers  are  intact,  paretic  (dilatation),  or  have  increased  power 
(hypertrophic  cirrhosis).  Finally,  this  vicarious  activity  becomes 
exhausted,  possibly  an  atrophy  of  the  intestines  also  develops,  al- 
though we  have  as  yet  no  absolute  proofs  of  this,  and  now  are  added 
the  symptoms  due  to  insufiicient  regeneration  of  the  blood,  a  picture 
which  may  be  very  similar  to  pernicious  anaemia,  unless  there  has 
been  such  a  gradual  failing  of  the  faculties  that  death  may  be  said 
to  have  resulted  ^'  from  old  age."  For  I  have  frequently  convinced 
myself  at  the  autopsy-table  that  in  many  of  the  cases  said  to  have 
died  from  old  age  there  has  actually  been  an  extensive  anadenia, 
usually  combined  with  dilatation  of  the  stomach.  The  similarity 
of  the  symptoms  to  those  of  pernicious  anaemia  has  already  *  been 

*  [Austin  Flint  was  the  first  to  call  attention  to  the  relation  between  anjemia 
and  atrophy  of  the  gastric  glands.  He  expressed  the  opinion  that  some  cases  of 
obscure  and  profound  anaemia  are  dependent  upon  degeneration  and  atrophy  of  tlie 
glands  of  the  stomach.  See  American  Medical  Times,  1860 :  New  York  Medical 
Journal,  March,  1871 ;  Flint's  Practice  of  Medicine,  Philadelphia,  1881,  p.  477.— 
Quoted  by  Welch,   loc.  cit,  p.  61G.— Tr.J 


336  DISEASES  OP  THE  STOMACH. 

noted  by  Fen  wick,*  Bartels,  f  Scheperlen,:}:  and  Osier.*  Rosen- 
heim II  has  observed  two  cases  which  seemed  to  be  pernicious  anae- 
mia. Inasmuch  as  these  cases  also  have  marked  changes  in  the 
blood,  alterations  in  the  red  corpuscles,  relative  increase  of  the 
white,  and  the  formation  of  macrocytes  and  microcytes,  the  question 
may  arise  whether  pernicious  anaemia  is  really  an  independent  dis- 
ease or  is  the  result  of  anadenia  of  the  stomach ;  but  in  the  cases 
of  pernicious  anaemia  described  by  Quincke,  and  also  by  Immer- 
mann,  the  changes  found  in  the  stomach  were  insignificant  as  com- 
pared with  the  intensity  of  the  symptoms.  A  striking  feature  which 
has  been  observed  by  several  writers  (Fenwick,  Ewald,  and  l^oth- 
nagel)  is  the  good  condition  of  the  subcutaneous  fat,  which,  however, 
is  not  often  found  in  disease  of  the  blood,  in  consequence  of  the  less- 
ened thoroughness  of  oxidation. 

IsTaturally,  this  variety  of  chronic  gastritis  is  especially  frequent 
in  older  persons,  since  the  compensatory  and  reconstituent  powers 
of  the  tissues  are  greater  in  the  young.  Most  of  the  cases  have  been 
over  forty  years  of  age,  and  in  the  two  young  patients,  eighteen  and 
twenty-one  years  old,  reported  by  Litten  ^  and  Einhorn,  the  diagno- 
sis was  not  verified  by  autopsy. 

However,  that  a  well-marked  atrophy  of  the  stomach  may  also 
occur  in  the  young  has  been  demonstrated  by  Westphalen,^  in  a 
case  which  was  very  carefully  observed  during  life,  and  the  diagno- 
sis verified  by  an  exact  microscopic  examination  of  the  stomach. 
The  patient  w^as  a  young  man,  twenty-eight  years  old,  who  presented 
the  symptoms  above  mentioned ;  the  diagnosis  was  made  of  motor 
insufliciencv  of  the  stomach  and  anadenia  of  the  mucous  membrane. 


*  S.  Fenwick.     Loc.  cit. 

f  Bartels.  Ein  Pall  von  pernicioser  Anamie  mit  Icterus.  Berliner  klin.  Woch- 
ensehr.,  1888.  No.  3. 

X  Scheperlen.  Studier  angaaende  Ansemie.  Nord.  medic.  Arkiv,  1879,  Bd.  xi, 
No.  3. 

*  Osier.  Atrophy  of  the  Stomach  with  the  Clinical  Peatures  of  Progressive  Per- 
nicious Aufemia.     American  Journal  of  Med.  Sciences,  1886,  No.  4. 

II  T.  Rosenheim.     Loc.  cit. 

^  M.  Litten  und  Rosengart.  Ein  Pall  von  fast  volligen  Erloschen  der  Secretion 
des  Magensaftes.  (Atrophic  der  Magenschleimhaut  der  Autoren.)  Zeitschrift  fiir 
klin.  Med.,  Bd.  14,  S.  573. 

()  Westphalen.     St.  Petersburger  med.  Wochenschr.,  1890,  No.  37  u.  38. 


DIAGNOSIS   OF  CHRONIC   GASTRITIS.  337 

As  tlie  emaciation  became  progressively  greater,  the  operation  of 
gastroenterostomy  was  performed.  The  patient  died  shortly  after 
the  operation.  The  resnlts  of  the  microscopic  examination  of  the 
stomach  coincided  entirely  with  the  statements  of  Lewy,  Ewald,  and 
Meyer. 

At  the  present  time  I  am  treating  a  young  druggist  who  has 
been  under  my  observation  for  over  two  years.  At  first  he  com- 
plained of  vague  dyspe23tic  symptoms,  weakness,  and  loss  of  weight. 
During  the  whole  course  of  his  illness,  in  spite  of  frequently  re- 
peated examinations,  not  even  a  trace  of  free  hydrochloric  acid  or 
pepsin  could  be  detected.  Even  the  administration  through  the 
tube  of  a  large  quantity  of  a  0"2-per-cent  hydrochloric-acid  solution, 
which  was  expressed  after  about  half  an  hour,  did  not  produce  any 
digestive  action  [in  the  test-tube]  as  occurs  in  healthy  individuals. 
The  patient  daily  takes  3"0  grammes  [gtt.  xlv]  of  hydrochloric  acid, 
Ph.  Germ,  (containing  25  per  cent  pure  HCl) ;  he  has  improved  so 
much  that  he  now  feels  very  well  and  works  all  day.  He  has  gained 
in  weight,  and  has  a  healthy  look.  The  last  time  I  saw  him  (Sep- 
tember, 1891)  I  was  again  unable  to  find  any  free  acid  in  the 
stomach-contents. 

In  my  opinion,  the  hydrochloric  acid  which  is  prescribed  has  no 
digestive  action  in  this  and  similar  cases.  As  has  already  been  ex- 
plained, the  patient  owes  his  good  condition  to  the  vicarious  action 
of  the  intestines  and  the  competency  of  the  muscular  fibers  of  the 
stomach,  which  promptly  propel  the  stomach-contents  on  into  the 
intestines.  The  acid  simply  prevents  their  decomposition,  while  the 
stomach  acts  merely  as  a  kind  of  reservoir  for  supplying  the  in- 
testines. 

Diagnosis. — The  objects  of  the  diagnosis  are,  first,  to  differentiate 
chronic  catarrhal  gastritis  and  its  results  from  other  diseases ;  and, 
secondly,  to  distinguish  its  varieties  from  one  another.  The  disease 
occurs  so  frequently  as  an  accompaniment  of  the  most  varied  local 
affections  of  the  stomach  that  I  will  disregard  its  secondary  occur- 
rence and  restrict  myself  to  the  genuine  varieties.  From  the  de- 
scription of  the  symptoms  already  given  it  may  readily  be  inferred 
that  the  diagnosis  of  such  a  true  gastritis  can  only  be  made  by  ex- 
clusion— that  is,  after  having  shut  out  all  the  other  organic  and  func- 


338  DISEASES  OF   THE  STOMACH. 

tional  disorders  of  the  organ.  An  idiopathic  gastritis  can  only  be 
diagnosticated  after  ulcer,  carcinoma,  dilatation,  neuroses,  or  any  of 
the  acute  disorders  already  described  has  been  excluded.  What  is 
left  is  gastritis ;  but  just  as  readily  as  the  diagnosis  "  ciironic  gastric 
catarrh"  is  made,  just  so  little  is  such  an  off-hand  opinion  justified 
in  many  cases ;  for  the  symptoms  of  chronic  gastritis  may  at  times 
simulate  any  of  the  above-mentioned  disorders,  and  neither  the  dura- 
tion, nor  the  etiology,  nor  the  kind  of  dys^^eptic  manifestations  will 
suffice  to  make  the  diagnosis  at  once,  but  in  addition  there  must  be 
a  careful  examination  with  the  aid  of  all  our  modern  diagnostic 
resources.  The  diagnosis  of  chronic  gastritis  having  been  made  in 
this  way,  the  next  step  is  to  determine  which  variety  we  have  before 
us.  Our  only  means  for  this  purpose  is  the  examination  of  the 
stomacli-contents.     The  results  of  these  may  be  grouped  as  follows : 

1.  Simple  chronic  gastritis.  "While  fasting,  the  stomach  con- 
tains only  a  small  quantity  of  a  watery,  mucous  fluid,  frequently 
tinged  yellow  or  yellowish-green  by  bile,  and  sometimes  mixed  with 
duodenal  contents  ;  on  standing,  it  deposits  a  sediment  containing 
epithelial  cells  of  various  sizes  and  shapes,  numerous  round  cells  and 
free  nuclei,  also  small  quantities  of  remnants  of  food,  starch  gran- 
ules, muscle  fibrillse,  and  vegetable  cellular  tissue.  After  the  test- 
breakfast  the  acidity  is  variable  but  never  increased  ;  the  quantity 
of  hydrochloric  acid  is  lessened.  Pepsin  and  rennet  are  small  in 
amount,  but  form  propeptone  and  peptone  even  in  the  stomach ; 
can  digest  after  acidulating.  Usually  contains  lactic*  and  fatty 
acids,  although  they  are  not  always  found. 

2.  Chronic  mucous  gastritis.  This  differs  from  the  simple  form 
by  the  abundance  of  mucus  in  the  contents  of  the  stomach  while 
fasting  and  after  taking  food,  so  that  acetic  acid  always  gives  a 
marked  mucin  reaction.  Acidity  always  low.  Hydrochloric  acid 
usually  absent,  Propeptone  very  abundant,  peptone  only  in  traces. 
Trial  digestion  [in  the  test-tube]  occurs  only  after  adding  hydro- 
chloric acid,  and  is  slow  even  then.  Curdling  by  rennet  is  tardy  or 
absent.     In  the  wash-water  after  lavage  small,  frequently  bloody 

*  By  "  absence  of  lactic  acid  "  I  mean  that  the  filtrate  of  the  gastric  contents 
gives  no  reaction  with  Uffelmann's  reagent,  either  as  such  or  in  the  ethereal  extract 
obtained  after  shaking  with  a  triple  volume  of  ether.     (See  above,  pp.  34  et  seq.) 


DIAGNOSIS  OF   CHRONIC   GASTRITIS.  339 

fragments  of  the  epithelial  covering  of  tlie  mucous  membrane  may 
occasionally  be  found. 

3.  Atrophy.  This  differs  from  the  two  varieties  already  named, 
in  that  while  fasting  the  stomach  is  usually  empty,  and  that  the 
chyme  expressed  after  the  test-breakfast  contains  neither  mucus, 
hydrochloric  acid,  pepsin,  nor  rennet.  At  all  events,  some  caution 
is  required  in  determining  the  absence  of  pepsin.  Jaworski  prop- 
erly calls  attention  to  the  fact  that  the  simple  addition  of  a  few 
drops  of  hydrochloric  acid  to  gastric  contents  containing  none  of 
this  acid,  before  trying  artificial  digestion  in  the  test-tube,  is  not 
sufficient  to  determine  the  presence  or  absence  of  pepsin.  On  the 
contrary,  enough  acid  must  be  added  till  the  color-tests  indicate  the 
presence  oifree  acid  ;  only  then  will  the  positive  or  negative  results 
of  the  digestion  experiments  be  decisive.*  For  a  long  time  I  have 
used  no  other  method,  and  I  confess  that  I  have  always  considered 
the  procedure  self-explanatory.  Now,  as  hydrochloric  acid  is  a  de- 
cided stimulant  for  the  secretion  of  pepsin,  or  rather  for  the  trans- 
formation of  pepsinogen  into  pepsin,  it  is  advisable  to  follow  Jawor- 
ski's  suggestion  in  cases  of  deficient  hydrochloric-acid  secretion 
where  we  wish  to  be  certain  of  the  absence  of  this  ferment :  200- 
300  c.  c.  [f  §  vjss. —  x]  of  diluted  hydrochloric  acid  are  adminis- 
tered, and  half  an  hour  later  the  stomach  is  siphoned ;  the  fluid  is 
then  tested  as  to  its  digestive  powers,  and  by  using  suitably  diluted 
portions  we  may  obtain  an  approximate  idea  of  the  amount  of  pep- 
sin present,  f 

ISTaturally,  no  tissue  elements  of  the  glandular  parenchyma  are 
to  be  found  in  the  contents  of  a  totally  atrophied  stomach  ;  a  few 
degenerated  round  cells  and  micro-organisms  may  be  all  that  is 
found. 

These  differences  will  generally  enable  us  to  distinguish  the  dif- 
ferent varieties  of  the  disease.  Yet,  as  already  stated,  there  are 
intermediate  forms,  especially  between  the  simple  and  the  mucous, 
which  can  not  be  definitely  classified.     However,  the  greatest  diag- 

*  [All  the  methods  thus  far  proposed  for  making  quantitative  estimations  of 
pepsin  are  tedious  and  complicated.     See  Boas,  loc.  cit.,  p.  24. — Tr.] 

f  Jaworski.  Zur  Diagnose  des  atrophischen  Magenkatarrhs.  Verhandlungen 
des  vii.  Congresses  fiir  innere  Medicin.     Wiesbaden,  1888. 


340  DISEASES  OF  THE  STOMACH. 

nostic  difficulty  is  encountered  in  differentiating  atrophy  or  anadenia 
of  the  stomach  from  the  cases  of  gastric  neuroses  and  carcinoma, 
accompanied  by  complete  loss  of  secretion.  From  the  neuroses  it 
may  be  distinguished,  as  a  rule,  by  the  fact  that  these  occur  usually 
in  middle-aged  or  young  persons,  and  that  their  course  is  irregular, 
while  atrophy  occurs  in  older  persons  and  is  permanent.  Thus, 
for  a  lono-  time  I  have  been  treating  a  young  man  in  whom  the 
results  of  the  chemical  examination  are  always  those  of  atrophy,  but 
whose  other  symptoms  all  point  to  nervous  dyspepsia. 

The  chemical  differentiation  of  carcinoma  and  atrophy  is  much 
more  difficult — that  is,  where  the  ordinary  symptoms  of  the  former, 
tumor,  swelling  of  the  lymphatic  glands,  cachexia,  and  hsematemesis, 
are  absent ;  because  in  both  hydrochloric  acid,  pepsin,  and  rennet 
may  be  absent.  Here  only  one  symptom,  has  been  of  service  to  me  ; 
at  all  events,  it  is  also  a  very  valuable  point  in  the  diagnosis  of  can- 
cer. I  refer  to  the  bloody  color  of  the  stomach-contents,  due  to  the 
presence  of  altered  blood  pigment,  which  is  frequently  observed  in 
carcinoma,  even  where  there  has  been  no  hsematemesis ;  so  far  as  I 
know  at  present,  this  never  occurs  in  anadenia  of  the  gastric  mucous 
membrane. 

Course  and  Prognosis.— The  long  duration  of  chronic  gastritis  is 
indicated  by  its  name.  This  is  especially  due  to  its  tendency  to  re- 
lapses, or,  more  properly  speaking,  exacerbations ;  for,  even  in  ap- 
parently cured  cases  the  organ  is  left  in  such  a  sensitive  condition 
that  the  slightest  irritation,  or  even  a  dsviation  from  a  specified  diet, 
may  cause  a  fresh  attack.  Therefore  the  prognosis  of  the  disease 
should  not  be  considered  too  slightingly,  especially  as  in  prolonged 
cases  atrophy,  an  incurable  and  fatal  lesion,  may  be  developed.  A 
large  number  of  the  cases  which  are  usually  said  to  have  died  of  old 
age  really  perish  from  gastric  atroj)hy  ;  but  it  is  generally  not  recog- 
nized, since  its  symptoms  are  as  yet  not  well  known,  and  because 
the  macroscopic  changes  in  the  stomach  are  not  marked.  Finally, 
there  is  another  reason  why  the  significance  of  chronic  gastritis  is 
not  to  be  underestimated,  namely,  the  disturbances  of  nutrition  and 
the  resulting  deterioration  of  the  tissues  render  the  organism  less 
resistant  toward,  and  more  susceptible  to  a  series  of  other  poisons,  of 
which  I  shall  only  mention  tuberculosis  and  acute  articular  rheu- 


TREATMENT   OP  CHRONIC   GASTRITIS.  34I 

matism.  As  certain  as  it  is,  on  the  one  hand,  that  tuberculosis  leads 
to  gastric  catarrh,  so  probable  is  it,  on  the  other,  that  even  though 
the  latter  does  not  produce  the  predisposition  for  the  former,  yet  if 
the  stomach  trouble  is  once  present  it  favors  and  increases  the  ad- 
vance of  the  tubercular  infiltration. 

Treatment. — Our  remedies  must  be  divided  into  three  groups : 
(1)  those  which  aim  to  directly  replace  the  deficient  supply  of  gastric 
juice  ;  (2)  those  which  are  to  stimulate  the  depressed  functions  of  the 
organ  ;  (3)  those  which  are  capable  of  counteracting  the  irritant  sub- 
stances introduced  from  without. 

This  includes  the  use  of  hydrochloric  acid,  pepsin,  and  of  the  so- 
called  peptogenous  substances.  The  therapeutic  employment  of  the 
latter  depends  on  the  well-known  claims  of  Schiff  and  Herzen  of  the 
effects  of  certain  (peptogenous)  substances  (bouillon,  dextrin,  bread- 
crumbs) ;  *  but,  as  I  have  already  shown,  this  peptogenous,  or  rather 
pepsinogenous,  action  of  these  substances  depends  only  on  the  stimu- 
lation of  the  gastric  glands,  such  as  is  exerted  by  all  kinds  of  nutri- 
tious substances;  the  stomach  is  filled  with  active  digestive  sub- 
stances, the  peptic  power  of  which  must  be  of  assistance  to  the  in- 
gesta  which  are  swallowed  later.  Still,  Dujardin-Beaumetz  f  has 
proposed  an  elixir  peptogene,  which  consists  of  10  parts  of  dex- 
trin, 20  of  rum,  and  180  of  sugar-water ;  and  Labastide  :j:  attributes 
to  peptone  enemata  the  power  of  at  once  relieving  obstinate  anorexia 
by  the  administration  of  peptogenous  substance^;. 

IlydrochloriG  acid  is  of  the  greatest  importance  in  the  treatment 
of  chronic  gastritis  because  it  not  alone  replaces  the  deficiency  in 
the  secretion  and  forms  acid  albuminates  so  essential  for  peptoniza- 
tion, but  also  because  it  prevents  organic  fermentation,  or  lessens  it 
if  already  present.  Apparently  in  relation  to  such  organic  fermen- 
tations even  Heberden  says,  "  Potus  acidi  non  semper  nocent  aegris 
acore  ventriculi  lahorantibus  nonmrnquam  etiam  auxilio  sunt.''^  * 
Pemberton  says  the  same.     As  this  checking  of  fermentation  is  due 


*  Ewald.     Klinik,  etc.,  I.  Theil,  3.  Aiiflage,  S.    108.— A.  Herzen.     Altes   und 
Neues  iiber  Pepsinbildung,  Magenverdauiing  und  Krankenkost.    Stuttgart,  1885. 

f  Dujardin-Beaumetz.     Journal  de  therap.,  1880,  p.  828. 
X  Labastide.     Gazette  d.  hopit.,  1883,  p.  333. 

*  Quoted  by  Budd,  loc.  cii.,  p.  424. 


342  DISEASES   OF  THE   STOMACH. 

to  liydrocliloric  acid  alone,  it  is  wi'ong  for  some  writers  to  recom- 
mend lactic  or  citric  acid  instead  of  it,  for  thej  have  no  sucli  anti- 
fermentative  action.  In  all  cases  wliere  a  diminution  or  absence  of 
hydrochloric  acid  has  been  determined — i.  e.,  in  all  cases  of  chronic 
gastritis — it  is  therefore  to  be  given,  preferably  as  the  dilute  hydro- 
chloric acid  of  the  pharmacopoeia  *  in  large  quantities,  and  certainly 
in  larger  doses  than  have  thus  far  been  recommended.  Jaworski 
has  shown  that  considerable  quantities  of  hydrochloric  acid  may  be 
introduced  into  the  stomach  without  harm  ;  therefore,  1  order  it  in 
as  concentrated  a  watery  solution  as  possible — i.  e.,  as  sour  as  the 
patient's  mouth  will  tolerate — to  be  taken  three  or  four  times,  at  fif- 
teen minutes'  intervals,  after  the  meal  ;  a  glass  tube  should  be  em- 
ployed, as  the  prolonged  use  of  the  acid  affects  the  teeth.  Pills  may 
also  be  made  with  bolus  alba  (Ph.  Germ.)  [argilla]  and  a  few  drops 
of  dilute  muriatic  acid  ;  five  or  six  of  these  may  be  ordered  at  a  time, 
to  be  taken  with  a  glass  of  water.  I  have  prescribed  this  remedy 
for  months  at  a  time,  without  any  bad  effects. 

Pepsin  was  for  a  long  time  regularly  prescribed  with  the  muri- 
atic acid,  with  the  pernicious  idea  that  even  if  it  did  not  help,  it  ce:-- 
tainly  did  no  harm.  To-day,  however,  we  know  that  pepsin  is  pres- 
ent in  a  very  large  number  of  cases,  even  when  free  hydrochloric 
acid  is  absent,  and  that,  as  shown  by  Jaworski,f  and  as  I  can  corrob- 
orate from  one  of  my  own  cases,  of  permanent  absence  of  free  hydro- 
chloric acid,  pepsin  can  be  extracted  from  the  glands  of  the  human 
stomach  by  means  of  this  acid.  We  should  therefore  restrict  its  ad- 
ministration to  those  cases  in  which  its  absence  can  be  actually  proved 
— that  is,  to  cases  of  advanced  mucous  catarrh  and  of  atroj)hy.  It  is 
then  to  be  given  in  large  doses,  0*5 — 1*0  gramme  [gr.  vijss.  to  xv], 
preferably  dissolved  in  water  acidulated  with  hydrochloric  acid,  fifteen 
to  twenty  minutes  after  eating,  for,  even  though  small  traces  of  pep- 
sin are  said  to  liquefy  large  quantities  of  albumen,  yet  the  artifi- 
cial  pepsin  j^reparations  contain  a  considerable  amount    of    milk 


*  [Acid,  hydrochlor.  dil.  (Ph.  Germ.)  has  25  per  cent  pure  HCl. — Te.] 
f  W.  Jaworski.     Die  Wirkung  der  Sauren  aiif  die  Magenfunction  des  Menschen. 
Deutsch.  med.  "Wochenschr.,  1887,  Nos.  36-38.— Also,  Methoden  zur  Bestiramung 
der    Intensitat    der    Pepsinausscheidung.      Mlinchener   med.    Wochenschr.,  1887, 
No.  33. 


TREATMENT  OF  CHRONIC  GASTRITIS.  343 

sugar ;  *  and  further,  only  a  portion  of  the  pepsin  is  active,  because 
a  part  of  it  is  soon  carried  on  into  the  intestines.  In  cases  of  com- 
plete absence  of  hydrochloric  acid  it  would  seem  rational  to  admin- 
ister pancreatin  or  papoid.f  However,  experiments  made  under 
my  direction,  by  Dr.  Haafewinkel,  showed  that  the  various  prep- 
arations of  pancreatin  which  were  given  with  the  test-breakfast 
had  no  stimulating  effect  on  its  digestion. 

The  object  of  the  second  class  of  remedies  is  to  increase  the 
activity  of  the  glands.  Pre-eminent  in  this  group  is  lavage  of  the 
stomach,  which,  excepting  in  dilatation  of  the  stomach,  has  nowhere 
achieved  greater  success  than  in  chronic  gastritis.  This  is  true  of 
the  simple  and  especially  of  the  mucous  variety.  It  is  well  to  com- 
bine the  stomach-douche  with  the  lavage ;  this  is  continued  till  the 
wash-water  runs  off  perfectly  clear,  and  then  a  quantity  of  water  or 
7iiedicated  solution  may  be  left  behind  in  the  stomach. :{: 

At  first  we  use  clear  warm  water,  which  may  be  replaced  at  the 
conclusion  with  an  alkaline  or  antiseptic  solution,  as  the  case  may 
demand.  The  former  is  employed  where  mucus  is  abundant,  the 
latter  for  the  fermentative  processes.  The  great  advantage  of  the 
tube  is  that  we  can  introduce  much  larger  quantities  of  unpleasant  or 
irritating  substances  than  would  be  possible  by  the  mouth,  because 
they  can  be  removed  at  once.  Even  after  a  relatively  small  number 
of  washings  a  marked  improvement  in  the  local  process  and  a  great 
relief  to  the  patient  may  be  observed.  I  could  cite  a  large  number 
of  cases  to  corroborate  this,  but  I  shall  not  do  so,  because  there  is 
nothing  characteristic  about  them ;  jet  I  repeat,  that  cases  which 
have  resisted  the  usual  methods  of  treatment  for  months,  and  even 
years,  have  been  greatly  relieved  and  even  cured  by  lavage,  in  a 
relatively  short  space  of  time,  this  treatment  having  been  of  course 
accompanied  by  other  suitable  therapeutic  measures. 

When  the  condition  of  the  patient  prevents  a  systematic  use  of 
the  tube — the  patients  no  longer  object  to  the  use  of  the  much- 
abused  "  stomach-pump,^'  now  that  the  public  is  better  informed  of 

*  [Hence  the  great  advantage  of  Fairchild's  glycerinum  pepticum,  which  con- 
tains no  sugar.     See  foot-note,  p.  41. — Tr.1 

t  [Finkler.     Therapeutic  Gazette,  August  15,  18S7.— -Tr.] 
X  [See  addendum,  p.  361.— Tr.] 


344:  DISEASES   OP    THE  STOMACH. 

the  necessity  of  tlie  modern  methods  of  examination  and  treatment 
of  gastric  disorders — I  replace  it  by  ordering  large  quantities,  np  to 
half  a  litre  [pint],  of  a  one-per-cent  solution  of  common  salt  at  42°  C. 
[10T"5  Fahr.],  or  "Wiesbaden  Kochhrmmen,  or  warmed  Rakoczy 
[Kissingen]  water.  The  action  of  lavage  consists  in  the  removal 
from  the  stomach  of  remnants  of  food  which  have  remained  there 
unduly  long,  and  the  loosening  of  the  mucus  which  adheres  to  its 
walls,  partly  chemically,  partly  mechanically ;  furthermore,  the  in- 
troduction of  the  tube,  combined  with  the  entrance  and  exit  of  the 
water,  increases  the  peristalsis  and  strengthens  the  muscular  activity 
as  well  as  favorably  influences  the  glands,  or,  as  put  by  Oser,  "  it 
produces  a  healthy  reaction."  The  sodium  chloride  is  certainly  not 
without  value,  notwithstanding  the  fact  that  Pfeiffer  has  shown  that 
the  addition  of  it  in  artificial  digestion  lessens  the  digestive  power. 
The  experiments  of  Braun  and  Griitzner,  as  well  as  of  Boas,  agree 
that  the  addition  of  common  salt  to  the  blood  increases  the  secretion 
of  gastric  juice,  and  seem  to  me,  for  many  reasons,*  to  be  more  con- 
vincing than  experiments  with  the  incubator.  At  all  events,  the  re- 
sults at  Wiesbaden  and  Kissingen  and  of  daily  practice  disprove  it. 
Massage,  and  especially  electricity,  are  excellent  agents  for  strength- 
ening the  enfeebled  muscular  fibers  of  the  stomach  (gastric  insuffi- 
ciency or  atony).  As  stated  in  Lecture  II,  it  is  best  to  use  internal 
faradization  of  the  gastric  walls  by  means  of  Einhoi-n's  electrode 
or  my  modification  of  it.  The  stomach  is  filled  with  some  water  in 
order  to  diffuse  the  current  as  much  as  possible,  and  the  circuit  is 
closed  by  a  flat  electrode  (about  the  size  of  the  palm  of  the  hand) 
which  is  placed  on  the  epigastrium. 

Among  the  stimulants  of  the  glandular  secretion  we  must  not 
fail  to  consider  the  action  of  the  so-called  hitters  and  carminatives^ 
the  use  of  which  dates  back  to  antiquity,  although  recently  the  ex- 
periments of  Tschelzoff  on  dogs  and  of  Jaworski  f  on  human  beings 
seem  to  prove  the  contrary,  namely,  that  they  lessen  the  amount  of 
the  secretion.     On  tlie  other  hand,  Marcone,:}:  after  testing  sixteen 

*  Y%de  Ewald,  Klinik,  etc.,  I.  Theil,  3.  Aufl.,  S.  246. 

\  W.   Jaworski.      Experimenteller  Beitrag   zur  Wirlcung  und  therapeutischen 
Anwendung  der  Amara  und  der  Galle.     Zeitschr.  fur  Therapie,  1886,  No.  23. 
%  Marcone.     Riforma  medica,  June  8,  1891. 


TREATMENT   OF  CHRONIC   GASTRITIS.  345 

stomacliics  and  aromatics,  claims  that  all  of  them  increased  the  quan- 
tity of  the  gastric  juice.  lie  asserts  that  when  introduced  into  the 
empty  stomach  they  stimulated  the  secretion  of  gastric  Juice ;  if  ad- 
ministered with  the  food,  the  period  of  digestion  is  shortened,  the 
gastric  juice  increased  in  quantity,  and  the  peristalsis  heightened. 
After  section  of  the  vagi  in  the  neck  this  effect  was  not  obtained ; 
hence  there  must  be  a  direct  action  on  the  mucous  membrane  of  the 
stomach.  Possibly  varying  results  will  be  obtained  here  according 
to  the  intensity  and  extent  of  the  gastritis  and  the  reactive  power  of 
the  glandular  parenchyma.  The  success  of  quassia,  gentian,  kino, 
calumba,  chamomile,  vermuth,  pepjjermint,  and  recently  of  condu- 
rango  bark,  has  been  noted  by  too  many  and  too  good  observers  than 
that  it  should  depend  upon  crude  self-deception.  I  myself  have 
alwaj's  been  satisfied  with  quassia  and  condurango,  although  I  al- 
ways combine  them  with  hydrochloric  acid  in  such  proportion  that 
the  solution  contains  0'2  per  cent  of  pure  hydrochloric  acid.  It  is 
possible  (as  future  research  may  show)  that  they  chiefly  increase  the 
peristalsis,  and  that  this  more  than  counterbalances  any  diminution 
of  secretion.  An  especial  action  on  the  muscular  tone  has  always 
been  attributed  to  nux  vomica  or  its  alkaloid  strychnine  and  bella- 
donna, especially  in  drinkers  and  persons  with  weak  nervous  sys- 
tems. This  is  undoubtedly  true,  provided  we  substitute  large  doses 
for  the  customary  small  ones.  The  use  of  belladonna  has  already 
been  discussed  on  page  212.  I  usually  prefer  to  combine  the  tinct- 
ura  nucis  vomicae  with  a  decoction  of  one  of  the  above  stomachics 
in  such  proportion  that  at  least  ten  drops  are  in  each  tablespoonful : 

]^   Tinct.  nuc.  vomicae S'O  [f  3  j^] 

Decoct,  condurango loO'O  [f  §  v] 

M.     Sig. :  Tablespoonful  three  to  four  times  daily,  half  an  hour 
before  taking  food. 

Or  it  may  be  combined  with  belladonna,  as  follows : 

5.  Tinct.  belladonnge 5*0  [f  3  j^] 

Tinct.  nuc.  vomicas 10-0  [f  3  ijss.] 

Tinct.  castor,  canadensis -' lO'O  [f  3  ijss.] 

M.     Sig. :  twenty  drops  (!)  six  times  daily. 

*  [This  preparation  was  officinal  in  the  U.  S.  Pharm.  of  1870. — Tb.] 


346  DISEASES  OP  THE  STOMACH. 

We  may  also  follow  tlie  English  custom  and  give  ipecac  in  small 
doses  of  2  to  3  centigrammes  [gr.  -J— |]  with  the  extract,  nuc.  vomicse 
in  the  same  dose,  ordering  it  in  powders  thrice  daily,  half  an  hour 
before  meals. 

[The  claims  of  Penzoldt  *  for  orexin  as  a  true  stomachic  have 
only  partly  been  fulfilled.  On  account  of  its  irritating  properties  it 
can  not  be  used  in  any  real  lesion  of  the  stomach ;  it  has  been  em- 
ployed in  phthisis,  ansemia,  convalescence,  etc.  It  may  be  prescribed 
in  doses  of  0'l-0*2  [gr.  jss.-iij]  or  more  with  extract  of  gentian ;  pref- 
erably in  tablets  or  gelatin-coated  pills.] 

The  hydriatic  measures — cold  rubbings,  douches  to  the  epigas- 
trium (highly  j3rized  by  the  ancients,  and  known  as  cataclysinus), 
and  massage — are  also  useful.  Apparently  irrational  is  the  use  of 
alkaline  waters,  for  example,  as  recommended  by  G.  See,  half  an 
hour  before  meals.  But  since  Jaworski  has  shown  that  carbonic- 
acid  waters  strongly  stimulate  the  chemical  activity  and  absorption, 
their  action  may  probably  be  explained  in  that  way ;  on  the  other 
hand,  they  neutralize  where  the  secretion  of  acid  is  marked. 

TJte  regulation  of  the  diet  of  the  dysjpejptic  hegins  m  the  mouth. 
"We  have  already  seen,  in  the  etiology  of  chronic  gastritis,  that  two 
important  factors  were  the  care  of  the  teeth  and  slow  eating— that  is, 
a  sufficient  disintegration  and  insalivation  of  the  food  in  the  mouth. 
Although  the  care  of  the  mouth  is  now  much  more  generally  ob- 
served than  formerly,  yet  only  too  often  do  we  still  find  examples 
of  shocking  neglect.  I  will  not  mention  poorly  cleansed  teeth  cov- 
ered with  tartar,  caries,  diseased  alveoli,  or  infiamed  gums  with  a 
thick  whitish-green  coating  of  desquamated  epithelium,  fungi,  cocci, 
and  remnants  of  food  between  the  teeth.  These  are  so  prominent 
that  they  are  noticed  at  once ;  and  we  ought  always  to  recommend 
the  patients  (and  healthy  persons  as  well)  to  brush  the  teeth  after 
each  meal.  Less  apparent  is  the  layer  of  filth  which  covers  the 
plates  of  artificial  teeth,  or  the  broken-otf  stumps  beneath  them. 
Kaczarowski  has  exaggerated  these  conditions,  but  he  is  certainly 
right  in  many  cases.     Thus,  not  long  ago,  a  man  consulted  me  for  a 

*  [Penzoldt.  Salzsaures  Orexin,  ein  eehtes  Stomachicum.  Therapeut.  Monats- 
hefte,  Bd.  iv,  1890,  p.  59.  Other  papers  on  this  subject  may  be  found  in  this  vol- 
ume, pp.  287,  374,  496,  and  Bd.  v,  1891,  pp.  203,  309,  364.— Tr.] 


TREATMENT  OF   CHRONIC   GASTRITIS.  347 

typical  mucous  catarrli ;  he  liad  a  false  upper  plate  and  na'ivelj  ad- 
mitted that  he  never  removed  his  teeth  at  night,  and  only  cleansed 
them  about  every  third  day.  The  plate  was  covered  with  a  dirty- 
white  coating  consisting  of  numerous  fungi  and  masses  of  cocci, 
while  the  hard  palate  was  markedly  reddened  and  dotted  with  small 
aj^hthous  ulcers.  In  the  slimy  stomach-contents  there  were  small 
brown  streaks  which  consisted  of  granular  blood  pigment  and  num- 
berless fungi  and  yeast-cells.  The  patient's  complaints  were  rela- 
tively slight  and  began  only  after  his  treatment  by  the  dentist.  In 
this  case  the  swallowed  bacteria  unquestionably  kept  up  a  constant 
state  of  irritation  of  the  gastric  mucous  membrane. 

The  importance  of  eating  slowly  has  been  told  thousands  of  times. 
A  striking  example  of  this  is  the  fact  that  many  people  with  weak 
stomachs  while  on  a  journey  can  digest  the  poor  food  of  the  hotels, 
because  they  have  nothing  else  to  do,  and  stay  a  long  time  at  the 
table,*  yet  they  suffer  from  the  carefully  prepared  and  selected 
dishes  at  home  which  are  rapidly  consumed  while  the  mind  is  occu- 
pied with  business  cares.  Upon  similar  psychical  grounds  is  based 
the  observation  that  many  dishes  are  sometimes  well  borne  by  dys- 
peptics, while  at  other  times  they  cause  great  discomfort,  according 
to  the  mental  or  bodily  condition.  Many  persons  also  have  a  marked 
idiosyncrasy  toward  certain  dishes,  and  for  others,  again,  an  entirely 
voluntary  and,  as  it  were,  unjustifiable  tolerance.  In  the  course  of 
practice  you  will  frequently  meet  patients  who  assert  that  they  can 
tolerate  rich  mayonnaises,  pastries,  tough  or  fat  meat,  as,  for  exam- 
ple, lobster  or  goose,  but  who  suffer  intensely  after  a  cup  of  milk  or 
bouillon.  As  a  result,  every  physician  who  has  much  to  do  with 
diseases  of  digestion  sooner  or  later  ceases  to  forbid  individual 
dishes,  but  will  be  guided  by  the  patient's  experience.  There  is  a 
certain  amount  of  truth  in  the  saying  of  G.  See,  "  En  France  on 
petit  Men  souniettre  un  menu  au  malade,  en  Allem.agne  on  Vy  sou- 
metP  One  can  only  indicate  the  fundamental  principles  of  dietetics 
concernino;   the  form   and   amount  of   food.*     Thus  it   is  natural 


*  [This  subject  is  very  well  discussed  in  Sir  William  Roberts's  recent  work  on 
Digestion  and  Diet,  London,  1891,  pp.  160  et  seq.  A  good  review  of  this  chapter 
will  be  found  in  the  American  Journal  of  the  Medical  Sciences,  1891,  vol.  ci,  p.  397. 
— Tr.] 


348  DISEASES  OF  THE  STOMACH. 

where,  for  instance,  tlie  digestion  of  albuminoids  is  difficult,  that 
this  class  of  food,  be  it  in  the  form  of  eggs  or  meat,  should  be  re- 
duced as  far  as  possible,  and  that  what  is  allowed  should  be  given 
in  the  most  digestible  condition.  Therefore  forbid  hard-boiled  eggs, 
meat  with  very  tough  fibers  and  tendons,  the  flesh  of  too  old  ani- 
mals or  of  those  which  have  just  been  slaughtered,  in  which  the  post- 
mortem formation  of  acids  has  not  jet  had  an  oj^portunitj  to  soften 
it.  For  the  same  reason  warmed  meat  is  to  be  forbidden,  also  that 
which  contains  too  much  fat,  like  pork,  fat  portions  of  lamb,  fat 
fowl,  fish  and  mollusks  (salmon,  carp,  turbot,  eel,  lobster,  crabs,  oys- 
ters*), sausages,  smoked  fish  like  flounder,  herring,  eel,  sprats,  lam- 
prey, etc.  Under  the  direction  of  Penzoldt,  Gigglberger  f  has  ex- 
perimented with  various  articles  of  food  prepared  in  as  many  ways 
as  possible,  the  tube  being  used  to  introduce  them  into  the  stom- 
ach of  living  persons.  His  results  practically  agree  with  those  of 
Beaumont.:}:  According  to  him,  meat  remains  in  the  stomach  be- 
tween two  hours  and  twenty-five  minutes  (stewed  calf-brain)  and  five 
hours  and  twenty-five  minutes  (roast  mutton).  In  general,  roasted 
meats  remain  somewhat  longer  in  the  stomach  than  stewed.  Heavy 
cheeses  are  also  indigestible  ;  hence  the  old  proverb  that  they  are 
gold  in  the  morning  but  lead  at  night.  I  also  consider  that  bouillon 
is  not  indicated,  not  on  account  of  its  albuminoids,  but  because  the 
high  percentage  of  salts  which  may  irritate  the  gastric  mucosa. 
Among  irritant  ingesta  may  also  be  included  strong  acids,  like  vine- 
gar, strong  condiments,  and  alcohol  in  concentrated  form  as  liqueurs. 
Indirectly  injurious — that  is,  by  their  products  of  decomj)osition — 
are  the  fats,  and  hence  oils  and  fatty  sauces  should  not  grace  the 
dyspeptic's  table.  A  substitute  for  meat  may  be  found  in  the  peptone 
preparations  and  peptone  chocolate ;  *  the  latter  is  expensive,  but 


*  H.  Chittenden.  On  the  Relative  Digestibility  of  Fish  Flesh  in  the  Gastric 
Juice.  Anier.  Chemic.  Journ.,  vol.  vi,  No.  5.  Chittenden  ruthlessly  destroys  the 
legend  of  the  great  digestibility  of  oysters,  and  places  them  at  the  foot  of  his  table. 

f  X.  Gigglberger.  Ueber  die  Dauer  der  Magenverdauung  von  Fleisehspeisen. 
Inaug.  Dissertation.     Erlangen,  1886. 

%  Vide 'Ewald.    Klinik,  etc.     I.  Theil,  3te  Auflage,  S.  114. 

*  [Parke,  Davis  &  Co.  have  recently  introduced  a  similar  preparation,  Mosquera's 
beef-cacao ;  a  tablcspoonful  of  the  powder  is  added  to  a  cup  of  hot  milk,  and  is 
boiled  five  minutes  like  ordinary  cocoa.     It  is  quite  palatable. — Tr.] 


TREATMENT   OP   CHRONIC   GASTRITIS.  349 

may  easily  be  prepared  at  lioine  by  boiling  some  cocoa  free  from 
fat,  or  even  chocolate,  and  adding  some  peptone  or  meat  peptone. 

On  tlie  other  side  of  the  scale  of  nutritious  substances  are  the 
carboliydrates,  including  everything  from  pure  starch  preparations 
to  the  nitrogenous  flours,  vegetables,  fruits,  and  legumes.  Their 
digestion  is  easy,  provided  that  in  their  preparation  as  much  starch 
as  possible  has  been  changed  into  dextrin  and  the  thick  consistency 
of  the  dough  formed  by  mixing  flour  and  water  has  been  got  rid  of 
by  heat  and  drying  in  the  air.  Hence  all  freshly  baked  articles  are 
to  be  avoided ;  on  the  other  hand,  it  explains  the  digestibility  of  the 
various  flours,  and  soups,  jellies,  etc.,  prepared  from  them ;  also  of 
vegetables  and  fruits  when  they  are  freed  from  their  cellulose  and 
softened,  and  in  the  case  of  the  former  when  prepared  with  a  mini- 
mum amount  of  fat.  But  all  kinds  of  cabbage  are  to  be  avoided  be- 
cause the  carbohydrates  contained  in  them  are  especially  prone  to 
fermentation.  This  is  also  true  of  the  legumes,  and  hence  mashed 
peas  and  lentils  are  usually  poorly  borne.  On  the  other  hand,  the 
so-called  leguminous  fl(jurs,  which  may  now^  be  bought  in  many 
forms,  constitute  a  good  diet,  of  which,  however,  the  patients  usually 
tire  after  a  time.  But  it  must  never  be  forgotten  that  all  foods 
with  carbohydrates  very  easily  undergo  fermentation,  on  account  of 
the  sugar  which  they  contain ;  hence  they  must  be  used  with  cau- 
tion in  all  atonic  conditions  of  the  stomach."^ 

Milk  occupies  an  intermediate  place  among  the  above-mentioned 
substances  ;  theoretically  it  ought  to  be  the  best.  But  in  practice  it 
is  either  rejected  entirely  or  is  borne  only  for  a  short  time  by  many 
patients  ;  however,  it  may  be  given,  cooked  or  raw,  sweet  or  sour,  or 
with  soda,  hme  water,  or  rum.  It  must  also  not  be  forgotten  that 
an  exclusive  milk  diet  is  a  kind  of  slow  starvation,  and  that  to  live 
on  milk  alone  would  require  much  larger  quantities  than  the  ca- 
pacity of  the  stomach  would  allow.  Still,  a  high  nutritive  value  can 
be  given  to  milk  by  adding  the  so-called  milk  powder  —  i.e., 
milk  which  has  evaporated  to  dryness  and  pulverized ;  of  this,  100 
grammes  [d^  ounces]  represent  about  one  litre  [quart]  of  milk. 


*  [The  absence  of  sugar  in  Schreiber's  dietetic  wine  (E.  Loeb  &  Co.,  55  War- 
ren Street,  New  York  citv)  renders  it  useful  in  this  class  of  patients. — Ta.] 


850  DISEASES  OF  THE  STOMACH. 

Finally,  dyspeptics  must  not  forget  the  general  rule  never  to 
fully  satisfy  their  appetite,  but  to  stop  as  soon  as  they  feel  the  first 
sensation  of  satiation,  and  to  allow  sufficiently  long  intervals  to  in- 
tervene between  meals. 

Fluids  are  not  to  be  taken  too  hot  nor  too  cold,  nor  in  too  large 
quantities,  since  they  unnecessarily  dilute  the  gastric  juice.  Dys- 
peptics should  also  avoid  all  strongly  carbonated  waters  and  those  in 
which  fermentation  readily  occurs,  since  the  stomach  becomes  dis- 
tended and  the  blood  surcharged  with  carbonic-acid  gas  ;  for  there 
are  very  few  cases  in  which  its  stimulating  effects  neutralize  these 
disadvantages.*  As  bland  beverages  we  may  use  the  time-honored 
orgeat,  rice  water,  and  decoctions  of  hops,  salep,  and  barley. 

That  the  regulation  of  the  diet  must  be  combined  with  attention 
to  general  hygiene  needs  hardly  be  mentioned  in  our  times.  The 
care  of  the  skin  and  lungs — in  short,  the  care  to  obtain  good  pure 
air — constitute  the  most  important  part,  not  alone  of  the  prophylaxis, 
but  also  of  the  treatment  of  nearly  all  chronic  diseases.  But  it  is  just 
in  cases  of  chronic  gastric  catarrh  that  much  harm  is  done,  because 
most  patients  think  that  they  have  done  their  duty  in  attending  to  a 
few  dietetic  details,  and  therefore  find  no  harm  in  spending  night 
after  night  in  a  hot  atmosphere  contaminated  with  gas,  crowded 
rooms,  smoke-filled  saloons,  etc.  The  dyspeptic's  programme  should 
always  include  active  bodily  exercise,  long  walks,  horseback-riding, 
baths,  sometimes  combined  with  douches,  gymnastic  exercises,  espe- 
cially those  which  call  the  abdominal  muscles  into  action  ;  and  as 
most  persons  do  not  carry  out  these  exercises  for  a  long  time  unless 
there  is  some  object  in  view,  they  should  be  taken  as  sport  or  mass- 
age. Rowing  is  a  specially  valuable  exercise,  and  with  the  present 
sliding  seats,  as  shown  anatomically  by  Mitan,f  offers  admirable  ex- 
ercise for  every  muscle.  It  is  to  be  regretted  that  women  can  not 
indulge  in  this  as  much  as  men,  yet  chamber  gymnastics,  massage, 
daily  walks  and  rides  can  accomplish  much  good.  '■'■  Maximeque 
qua  superiores  partes  moveat,  quod  genus  in  omnibus  stomachi  mtiis 

*  [These  remarks  apply  with  even  greater  force  to  the  use  at  meals  of  alkaline 
carbonated  waters  like  Vichy,  Seltzers,  etc. — Tr.] 

f  Mitan.  Das  Rudern,  eine  heilgymnastische  Uebung.  Inang.  Dissertation. 
Berlin,  1883. 


TREATMENT   OF   CHRONIC   GASTRITIS.  351 

aptisshnum  est,''''  says  Celsus  ;  yet  it  would  be  even  better  to  bring 
the  body  into  moderate  action  but  not  overexertion. 

Finally,  some  special  jDoints  in  the  treatment  still  require  dis- 
cussion. 

Fermentation  and  decomposition  of  the  food  in  the  stomach  are 
best  treated  by  means  of  lavage  ;  its  systematic  emj^loyment  will 
prevent  stagnation  of  the  ingesta,  and  thus  the  chief  factor  of  de- 
composition is  at  once  removed.  Where  this  is  impossible,  we  must 
use  antifermentative  drugs ;  but  it  must  be  premised  that  these  are 
useless  unless  at  the  same  time  the  diet  is  regulated,  because  the 
stomach  will  not  tolerate  the  large  doses  of  these  drugs  which  would 
be  necessary  where  there  are  large  accumulations  of  objectionable 
food.  It  is  for  this  reason  that  these  substances  are  useless  in  dila- 
tation of  the  stomach  with  accumulations  of  large  quantities  of 
fermenting  ingesta.  Otherwise  we  may  expect  good  results  from 
creosote  and  thymol,  in  doses  up  to  O'l  gramme  ["nijss.],  in  pills, 
emulsion,  or  with  a  mucilaginous  vehicle ;  they  are  the  best  of  this 
class  of  remedies,  for,  according  to  my  own  experience,  there  is 
much  less  certainty  in  the  action  of  salicylic  acid,  carbolic  acid, 
benzoic  acid,  naphthalin,  etc. 

Excellent  antisepsis  may  be  obtained  with  bismuth  salicylate, 
beta-naphthol,  and  a  new  preparation,  benzonaphthol.*  The  latter 
is  preferable  to  beta-naphthol  on  account  of  its  freedom  from  odor 
and  taste.  Eesorcin  is  also  valuable,  but  it  must  be  used  in  an  abso- 
lutely pure  form,  as  so-called  resorcinum  resublimatum.  I  prescribe 
these  preparations  either  as  powders — 
^p  Beta-naphthol, 

Bismuthi  salicylatis aa       Y"5  [  3  ij] 

Pulv.  rhiz.  calami  (Ph.  Ger.)  f 10-0  [  3  ijf ] 

]S"atrii  bicarbonatis, 

{si'Ve  Sacchari  lactis) aa  15-0  [  §  ss.] 

M.     Sig. :    Teaspoonful  every  two  hours. 

(Benzonaphthol  or  resorcin  may  be  used  instead  of  beta-naphthol.) 
— or  in  solution  with  rhubarb  or  a  stomachic : 

*  [See  Merck's  Bulletin,  New  York,  January,  1892,  p.  27.— Tr.] 
f  [Acorus  calamus,  U.  S.  P. — Tb.] 


352  DISEASES   OP  THE   STOMACH. 

;p  Resorcini  resublimati 5*0  [gr.  Ixxv] 

Infusi  radicis  rhei 5-0  :  150-0  [gr.  Ixxv  :i^Y] 

Yini  condurango ad  200-0  [f  5  vjf] 

M.     Sig. :  Tablespoonful  every  two  hours. 

I  have  had  no  experience  with  bisnlphide-of-carbon  water  pro- 
posed by  Dnjardin-Beaumetz.*  Chloral,  with  its  sedative  and  anti- 
fermentative  action,  has  been  of  great  service  to  me  in  cases  of 
moderate  fermentation  accompanied  by  gastralgia.  The  three  cases 
of  agoraphobia  cited  above  [p.  332]  were  all  cured  with  chloral.  I 
order  a  tablespoonful  of  a  3  to  5  per  cent  solution  to  be  taken  every 
two  hours. 

I  wish  to  call  attention  once  more  to  the  antifermentative  action 
of  a  systematic  use  of  hydrochloric  acid.  You  also  know  that  the , 
symptoms  due  to  fermentation  may  be  relieved  or  lessened  in  a 
short  time  by  sufficient  doses  of  alkalies,  as  bicarbonate  of  soda  in 
5  to  10  grain  doses  alone  or  combined  with  rhubarb  or  bismuth  ;  but 
it  is  simply  palliative,  and  favors  rather  than  opposes  the  cause  of 
the  process.f 

The  proper  use  of  antifermentatives  also  puts  an  end  to  the 
formation  of  gas,  and  hence  it  is  unnecessary  to  have  recourse  to 
the  use  of  the  more  than  questionable  drugs  recommended  to  absorb 
gas.  The  use  of  charcoal  is  utterly  irrational ;  it  has  recently  been 
brought  into  commerce  in  the  form  of  "  charcoal  cakes  " ;  the  char- 
coal becomes  moist  in  the  stomach,  and  in  that  condition  its  absorp- 
tive powers  for  gas  are  entirely  lost. 

Where  gastralgis  resist  all  ordinary  forms  of  treatment  with  the 
various  opiates  they  may  be  temporarily  relieved,  preferal}ly  by  a 
hypodermic  injection  of  morphine.  Hyoscyamus,  hydrocyanic  acid, 
and  belladonna  as  well  as  chloroform  water  (1  to  200)  have  also  been 
recommended  for  this  purpose.  I  have  found  the  following  com- 
bination very  useful : 

'^  Morphinse  hydrochloratis 0-2  [gr.  iij] 

Cocain.  hydrochloratis 0-3  [gr.  v] 

Tinct.  belladonna 5-0  [f  3  j  i] 

Aq.  amygdalse  amarae 20*0  [f  3  v] 

*  Dujardin-Beaumetz,     Les  nouvelles  medications.     Paris,  1886,  p.  70. 

f  [See  Sir  William  Roberts.     British  Med.  Journal,  1889,  vol.  ii,  p.  373.— Tr.] 


TREATMENT  OP  CHRONIC   GASTRITIS.  353 

M.  Sig.  :  Ten  to  fifteen  drops  every  hour.  Where  the  pains  are 
very  severe,  three  doses  of  ten  drops  each  within  an  hour. 

Budd  attributes  a  sedative  action  to  Fowler's  sohition,  taken  half 
an  hour  before  eating,  while  Siebert*  has  even  come  to  the  con- 
clusion that  with  the  use  of  arsenic  the  pains  of  nervous  or  catarrhal 
gastralgia  disappear  in  a  few  days,  but  persist  where  it  is  due  to  an 
ulcer. 

Germain  See  has  recently  spoken  very  highly  of  the  use  of  ex- 
tract, cannabis  indicse  in  gastralgias  of  all  kinds,  and  has  laid  espe- 
cial stress  upon  the  fact  that  it  acts  only  locally  on  the  mucous  mem- 
brane of  the  stomach,  and  not  upon  the  general  nervous  system.  I 
can  not  agree  with  this  sweeping  recommendation.  It  is  true,  I 
have  obtained  analgesic  effects  from  its  use  in  some  patients ;  others 
were  attacked  with  severe  cerebral  symptoms,  like  intoxication  and 
headache  ;  in  still  others  it  had  no  effect  whatsoever. 

Codeine,  especially  codeine  phosphate,f  acted  much  better,  I 
prescribe  it  either  in  drops  like  the  morphine  drops  above  mentioned 
(replacing  the  morphine  by  codeine,  but  in  double  the  quantity,  0*4 
[gr.  vj]),  or  as  powder  with  bismuth  subnitrate : 

]^  Codeinse  phosphatis 0-02-0-015  [gr.  |-J] 

Bismuthi  subnitratis 0'3  [gr.  v] 

Sacchari  lactis 0'2  [gr.  iij] 

M.     Sig. :  Tal.  dos.  every  two  hours. 

Purgatives. — Irregularity  of  the  bowels  plays  a  very  important 
part  in  all  forms  of  chronic  gastritis.  In  the  early  part  of  this  work 
I  have  called  attention  to  the  close  connection  between  the  intestines 
and  the  stomach,  and  have  repeatedly  pointed  out  that  many  so- 
called  stomach  troubles  are  really  in  the  intestines.  Although  I 
shall  reserve  a  detailed  description  of  these  conditions  for  the  por- 
tion of  this  work  devoted  to  the  diseases  of  the  intestines,:{:  yet  the 
use  of  purgatives  must  be  considered  here,  since  they  not  alone  re- 
lieve the  intestinal  disturbances,  but  also  directly  aid  the  passage 


*  Siebert.  Ueber  Magenschmerz  und  Magengeschwiir.  Deutsche  Klinik,  No.  10, 
1852. 

f  [Codeine  phosphate  is  often  preferable  to  codeine,  on  account  of  its  solubility  ; 
the  ordinary  dose  is  0-1  [gr.  jss.]  :  the  daily  dose  is  0*4  [gr.  vj]. — Tr.] 

X  [This  portion  of  this  work  has  not  yet  been  published. — Tk.] 


354:  ,  DISEASES   OP   THE  STOMACH. 

of  the  stomacli-contents  into  tlie  intestine  by  securing  prompt  evac- 
uations. In  the  same  way  those  drugs  which  act  as  cholagogues 
also  increase  the  peristalsis  of  the  intestines,  and  hence  empty  the 
bowels.  In  the  vast  majority  of  cases  of  chronic  gastritis  we  must 
combat  constipation  and  not  diarrhoea. 

"NYe  may  at  once  eliminate  one  group  of  purgatives,  the  vegetable 
oils,  of  which  the  typical  example  is  castor  oil ;  it  irritates  the  stom- 
ach and  nauseates  most  patients  even  when  given  in  an  emulsion. 
Although  it  has  undoubtedly  been  very  useful  in  many  cases  of  so- 
called  stomach-catarrhs,  yet  it  is  just  in  these  cases  that  the  real  trouble 
is  in  the  intestines  and  not  in  the  stomach,  and  the  injurious  effects 
on  the  latter  are  more  than  counterbalanced  by  its  beneficial  action 
on  the  former.  I  have  even  been  able  to  demonstrate  experiment- 
ally the  disturbing  effect  of  oil  on  the  chemical  processes  of  diges- 
tion,"*^ Saline  cathartics  are  also  only  to  be  given  when  an  action 
on  the  small  intestines  is  desired ;  then  the  sulphate-of-soda  mineral 
waters  are  to  be  used,  or,  as  these  are  usually  insufficient,  the  salt 
itself  in  substance.  An  excellent  remedy  is  sulphate  of  soda  in 
combination  with  rhubarb  and  carbonate  of  soda ;  it  is  the  old  sola- 
171671  Tiypochondriamivi  of  Kleist  which  has  recently  been  recom- 
mended by  Leube : 

:^  Pulv.  rad.  rhei . .    20*0  [  3  v] 

Sod.  sulphat 10*0  [  3  ijss.] 

Sod.  carbonat., 

Sod.  bicarbonat aa    5*0  [gr.  Ixxv] 

M.  Sig. :  At  bedtime,  \  to  \-\\  teaspoonfuls  in  a  glass  of 
warm  water,  as  may  be  necessary. 

According  to  the  individual  indication  this  may  be  changed  and 
magnesia  usta,  or  tartaric  acid,  or  sulphate  of  potash  may  be  added  ; 
or,  as  I  prefer,  it  may  be  combined  with  bismuth  salicylate  and  ex- 
tract, nuc.  vomic.  (in  atony  of  the  stomach  with  tendency  to  flatu- 
lence from  intestinal  fermentation).  Here  I  may  also  mention 
cream  of  tartar  and  Rochelle  salt  or  tartrate  of  soda  (Ph.  Germ.) ; 
they  may  be  given  in  effervescing  lemonades,  in  powder  with  washed 


*  Ewald  und  Boas.    Zur  Physiologie  und  Pathologie  der  Verdauung.  II.    Vir- 
chow's  Archiv,  Bd.  104. 


TREATMENT  OF   CHRONIC   GASTRITIS.  355 

siilpliur,  or  in  decoctions  with  tlie  vegetable  aperients  spoken  of  in 
the  next  paragraph. 

Vegetahle  Aperients. — The  mildest  of  these  are  tlie  various 
fruits  which  owe  their  efficacy  to  their  vegetable  acids.  The  use  of 
stewed  prunes  at  night  before  retiring  is  well  known  ;  less  known  is 
a  mixture  of  two  parts  of  prunes  and  one  part  of  dried  figs :  the 
taste  is  agreeable  and  the  cathartic  action  is  mild.  Among  the  true 
laxatives  rhuljarb  stands  pre-eminent,  and  in  fact  it  is  a  very  valu- 
able aid  to  all  dyspeptics.  Kext  to  it  stand  tamarinds,  then  senna, 
buckthorn,  European  centaury  (ITerba  centaurii.  Ph.  Germ.),  tarax- 
acum, coriander,  fennel,  etc.,  some  as  extracts,  others  as  teas ;  of  the 
latter  the  best-known  preparation  is  the  so-called  Hamburg  tea. 
Senna  sometimes  causes  nausea  and  colic ;  this  may  be  avoided  by 
using  an  alcoliolic  extract  (extract,  sennse  fluid.)  or  by  adding  some 
aromatic  spirits  of  ammonia  or  tincture  of  cardamom.  Cascara  sa- 
grada,  which  has  been  so  extensively  used  recently  (50  to  80  drops 
of  the  fluid  extract  at  night),  is  a  mild  and  at  first  a  certain  remedy, 
but  like  the  rest  of  this  class  it  loses  some  of  its  effects  in  time.* 
Extract,  fab.  calabaric.  (Ph.  Germ.)  [ext.  physostigmatis,  U.  S.  P.] 
0"05  [gr,  f]  to  lO'O  [  3  ijss.]  of  glj^cerin  has  had  a  very  variable  ac- 
tion in  my  hands. 

Aloes  act  especially  on  the  large  intestines,  either  alone  or  com- 
bined with  jalap,  colocynth,  or  seammony.  English  writers  also  con- 
sider it  a  stomachic  and  give  it  especially  with  calomel,  to  which,  as 
is  well  known,  a  cholagogue  as  well  as  a  cathartic  action  has  been 
attributed.  But,  as  Putherford  has  shown  that  podophyllin  is  also 
a  cholagogue,  and  as  it  has  the  advantage  over  calomel  of  having 
none  of  its  after-effects,  I  prefer  to  use  it  with  aloes,  etc.,  instead  of 
calomel. 

Enemata  also  deserve  mention  ;  they  may  consist  of  warm  water 
alone  or  with  salt,  soap,  decoction  of  senna,  castor  oil,  and  the  like. 
It  is  an  old  rule,  originally  given  by  Trousseau,  that  they  should 

*  [This  drug  may  also  be  used  as  a  stomachic  as  well  as  a  laxative. 

;^     Tr.  nueis  Tomicis lO'O  [  3  ijss.] 

Ext.  cascarse  sagradse  fluidi, 

Elix.  aurantii aa    40-0  [  3  x] 

Aquam ad  120-0  [  §  i v] 

M.     Sig. :  Teaspoonful  fifteen  minutes  before  eating. — Tk.J 
23 


356  DISEASES  OF  THE  STOMACH. 

never  be  given  immediately  after  a  meal,  since  tliej  may  then  easily 
cause  severe  diarrlioeal  discharges  instead  of  easy  movements  ;  but  it 
is  only  recently  that  attention  has  been  called  to  the  fact  that  no 
hard  rubber  or  horn  syringes  should  be  introduced  into  the  rec- 
tum ;  instead  a  soft,  flexible,  thick  rubber  tube,  with  one  opening 
below  and  several  laterally,  should  be  passed  quite  high  up,  and  the 
fluid  permitted  to  enter  or  force  its  way  slowly.  Enemata  are  of 
especial  value  where  the  large  intestine  is  relaxed ;  tliey  soften  the 
hard  fsecal  masses  which  accumulate  in  the  sigmoid  flexure  and  de- 
scending colon,  and  they  also  gently  stimulate  the  muscular  fibers  of 
the  lower  segment  of  the  intestine.  Upon  the  latter  also  depends 
the  action  of  the  injections  of  small  quantities  of  glycerin  (which 
constitutes  the  active  ingredient  of  the  so-called  "  O^'dtmann's  pur- 
gative ")  and  of  the  glycerin  suppositories  which  are  made  of  glycerin 
and  any  easily  melting  substance.  As  long  as  the  enemata  operate 
(i.  e.,  as  long  as  we  are  only  dealing  with  the  so-called  torpidity  of 
the  lower  bowel),  they  are  the  best  and  mildest  means,  and  the  bad 
results  attributed  to  their  prolonged  use,  such  as  causing  catarrh  of 
the  intestines,  occur  in  very  few  cases.  Although  they  usually  lose 
their  effect  after  a  time,  yet  I  know  patients  wlio  have  successfully 
used  them  daily  for  years. 

Finally,  I  must  not  neglect  to  state  that  a  number  of  cases  of 
chronic  gastritis  can  not  be  cured  with  the  so-called  stomach  reme- 
dies,  but  require  treatment  for  the  primary  disease.  These  are 
especially  the  gastric  catarrhs  which  occur  in  pulmonary,  cardiac, 
and  renal  diseases,  and  those  appearing  during  the  course  of  chloro- 
sis. But,  as  the  gastric  symptoms  sometimes  constitute  the  most 
prominent  part  of  the  patient's  complaints,  it  not  infrequently  hap- 
pens that  these  persons  are  for  a  long  time  treated  for  the  stomach 
trouble,  till  a  thorough  examination  reveals  the  real  condition,  and 
the  proper  treatment  of  this  relieves  the  gastric  symptoms. 

Mineral  Springs. — The  drinking  of  mineral  waters,  either  at  the 
springs  or  at  home,  constitutes  an  important  part  of  the  treatment 
of  chronic  gastritis.  Drinking  the  water  at  home  is  only  an  expe- 
dient, and  will  never  replace  the  great  advantages  of  a  residence  at 
the  spa  with  all  its  adjuvants ;  the  mental  and  bodily  rest  and  in- 
vigoration,  the  dolce  far  niente  of  life  at  the  springs,  the  constant 


TREATMENT  OF  CHRONIC  GASTRITIS.  357 

warning  against  dietetic  errors — all  tliese  are  lacking.  Tliis  is  true, 
even  though,  so  far  as  these  points  are  concerned,  many  well-situated 
people  could  just  as  well  take  the  cure  at  home.  But  in  spite  of 
every  care  in  filling  and  sending,  bottled  mineral  waters  never  have 
the  invigorating  freshness  nor  the  strength  of  the  bubbling  spring  ! 

For  the  local  treatment  of  stomach  troubles  the  following  four 
classes  of  mineral  waters  are  of  most  importance  : 

1.  Pure  salines. 

2.  Salines  with  a  large  amount  of  carbonic-acid  gas. 

3.  Alkaline  salines  in  which  the  proportion  of  sodium  chloride 
and  carbonic-acid  gas  is  much  less  than  that  of  intermediate  salts. 

4.  Alkaline  and  alkaline  -  muriatic  {alkaUsch  -  muriatische) 
waters.* 

Unfortunately,  I  must  confess  that  we  know  very  little  of  the 
action  of  these  mineral  waters  upon  the  stomach,  because  the  criteria 
upon  which  their  effects  are  judged  are  based  directly  upon  the  in- 
fluence on  the  intestines,  and  only  indirectly  take  cognizance  of  the 
stomach.     Just  at  present  this  position  is  rendered  still  more  aggra- 


*  The  following  springs  may  serve  as  types  of  these  classes : 

(1)  Wiesbaden  {Kochhrunnen). 

Sodium  chloride 6'83 

Calcium  chloride 0-47 

Calcium  carbonate 0*42 

Carbonic-acid  gas 0-5  c.  c.  to  the  litre. 

(2)  Kissingen  {Rakoczy). 

Sodium  chloride 5"82 

Calcium  chloride 0'28 

Calcium  carbonate 1'06 

Carbonic-acid  gas 1392-0  c.  c.  to  the  litre. 

(3)  Carlsbad  (Ifilhlbrunnen). 

Sodium  sulphate 2"39 

Sodium  carbonate i*27 

Sodium  chloride 1*02 

Carbonic-acid  gas 1'27  c.  c.  to  the  litre. 

(4)  Urns  (Kesselbrunneti). 

Sodium  carbonate 1'99 

Calcium  carbonate 0'22 

Sodium  chloride I'O 

Carbonic-acid  gas 553-2  c.  c.  to  the  litre. 

[For   further  information   concerning  these  and  other  springs,  see  George  E. 

Walton.     Mineral  Springs  of  the  United  States,  etc.     New  York :  D.  Appleton  & 

Co.,  1883.— Tr.] 


358  DISEASES  OF  THE  STOMACH. 

vating  because  tlie  experimental  researches  of  Pfeiffer  *  and  Jawor- 
ski  have  strongly  shaken  our  belief  in  the  influence  of  Glauber's 
salt  on  stomach  disorders.  Jaworski,  as  is  well  known,  has  con- 
cluded, from  his  investigations,  that  Carlsbad  water  stimulates  the 
gastric  secretion  only  in  the  beginning,  and  when  taken  in  small 
quantities ;  but  if  consumed  for  a  longer  time  it  lessens  it  markedly, 
may  finally  cause  it  to  disappear,  and  may  even  lead  to  atrophy 
of  the  glandular  parenchyma.f  At  my  request.  Dr.  Sandberg,  of 
Marstrand,  has  investigated  these  striking  results.  Consecutive  ex- 
aminations w^ere  made  on  ten  patients  during  a  four  to  five  weeks' 
treatment  at  Carlsbad ;  the  result  was  that  in  half  of  them  the  acid- 
ity was  somewhat  lessened,  in  the  others  increased ;  and  the  lessened 
acidity  was  just  in  those  patients  who  had  had  a  high  acidity  before 
beginning  the  treatment.  But  as  we  know  that  the  acidity  is  sub- 
ject to  very  great  variations  in  the  same  persons,  too  much  weight 
must  not  be  laid  upon  the  above  results,  especially  as  an  appreciable 
change  was  not  found  in  the  peptic  power  nor  in  the  action  of  ren- 
net. On  the  other  hand,  these  investigations  have  undoubtedly 
shown  that  Jaworski's  statements  must  be  modified — i.  e.,  that  the 
Carlsbad  water  has  the  perfidious  quality  of  destroying  the  chemical 
powers  of  the  stomach  in  the  short  space  of  four  to  six  weeks  !  At 
least  it  does  not  do  so  in  Berlin !  For,  strictly  speaking,  we  must 
depend  on  the  bottled  water  as  it  is  sent  to  us,  and  we  must  leave  it 
to  the  physicians  of  Carlsbad  "  to  rehabilitate  the  nymph  of  the 
spring  in  her  own  home,"  should  they  consider  that  necessary. 

For  the  influence  of  common-salt  mineral  waters  on  digestion  I 
refer  you  to  what  was  said  on  page  344,  and  add  that  Boas  j^  lias 
methodically  observed  the  changes  in  the  secretion  of  gastric  juice 
while  taking  warm  saline  waters ;  after  three  to  four  weeks  he 
noticed  a  decided  improvement  in  the  secretion  and  a  coincident 
disappearance  of  the  symptoms.  The  action  of  the  saline  waters 
(sodium  chloride)  depends  chiefly  on  a  stimulation  in  the  secretion 

*  E.  Pfeiffer.  Balneologisehe  Studien  uber  "Wiesbaden.  Wiesbaden,  1883,  chap- 
ter on  "  Kochsalz  oder  Glaubersalz  ?" 

f  W.  Jaworski.  Ueber  die  Wirkung  des  Carlsbader  Wassers  auf  die  Magendarm- 
f unction.     Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  xxvii. 

^:  J.  Boas.  Verhandlungen  des  Vereins  fiir  innere  Med.  zu  Berlin.  November  5, 
1888. 


TREATMENT   OF   CHRONIC   GASTRITIS.  359 

and  absorption  and  an  increase  in  the  metabolism.  This  is  also  true 
of  the  alkaline  saline  waters,  yet  it  seems  to  be  more  pronounced  in 
the  waters  with  sodium  chloride  than  those  with  sodium  sulphate. 
The  latter  and  the  alkaline  waters  have  such  a  high,  percentage  of 
alkali  that  they  can  act  as  antacids.  All  possess  the  property  of  dis- 
solving mucus.  The  saline  waters  stimulate  the  stomach's  activity, 
the  alkaline  saline  act  principally  on  the  intestines  and  liver.  The 
simple  mechanical  action  of  washing  out  the  stomach  is  common  to 
them  all. 

But  while  it  is  true  of  the  saline  and  alkaline  springs  that  they 
can  not  have  any  bad  effect  on  the  general  system,  or,  as  the  layman 
says,  "  they  are  not  ]30werful,"  yet  this  is  often  the  case  to  a 
marked  degree  with  the  sodium-sulphate  waters,  and,  especially  in 
nervous  and  ansemic  persons,  they  may  cause  an  increase  in  the  irrita- 
tive manifestations  or  the  signs  of  depression.*  Therefore  we  ought 
never  to  send  patients  with  pronounced  neuroses  of  the  stomach  to 
these  springs,  nor  even  allow  them  to  drink  any  of  these  waters. 
For  them  we  must  recommend  a  general  tonic  treatment  which  may 
vary  with  the  individual :  sometimes  only  a  stay  in  high  mountainous 
districts ;  others  need  the  sea-shore ;  others,  again,  require  a  hydro- 
pathic establishment  with  all  its  paraphernalia ;  in  still  others, 
mud  or  brine  baths,  together  with  small  doses  of  an  alkaline  muri- 
atic water,  are  indicated.  To  this  class  belong  the  great  group  of 
nervous  dyspeptics,  the  patients  with  atony  of  the  muscular  fibers 
of  the  stomach  upon  a  nervous  predisposition.  In  this  respect  my 
experience  tells  me  that  much  harm  is  done,  and  every  year  from  a 
number  of  patients  I  hear  the  same  complaint,  that  they  were  sent 
to  Carlsbad  on  account  of  chronic  catarrh  of  the  stomach,  but  that 
they  had  borne  the  treatment  very  badly.  Carlsbad  and  Marienbad 
are  frequently  these  patients'  greatest  enemies.  The  high  elevation 
of  Tarasp  causes  it  to  occupy  an  intermediate  position ;  Kissingen, 
"Wiesbaden,  Homburg,  E'auheim,  Franzensbad,  etc.,  or  the  sparkling 


*  By  way  of  addition  I  may  observe  that  I  find  that  so  experienced  a  physician 
as  Cordes  Qoc.  eit.,  p.  535)  expresses  himself  thus :  "  On  this  occasion  I  wish  to  warn 
most  emphatically  against  sending  irritable,  weak  patients  to  the  sodium-sulphate 
springs ;  for  they  operate  badly  in  every  case,  because  the  reflexes  proceeding  from 
the  stomach  and  intestines  of  themselves  are  very  pernicious." 


360  DISEASES  OP  THE  STOMACH. 

soda  springs  like  Yicliy,  Ems,  l^euenalir,  Bilin,  etc.,  are  more  indif- 
ferent, and  may  at  times  be  beneficial  on  account  of  the  change  of 
life  and  the  other  well-known  accessories  of  watering-jjlace  life. 

On  the  other  hand,  exj^erience  has  shown  that  the  alkaline-saline 
and  the  alkaline  springs  (to  say  a  few  words  in  anticipation  on  the 
treatment  of  the  gastric  neuroses)  are  very  beneficial  in  conditions 
of  hyperacidity  or  hypersecretion.  The  very  successful  use  of 
Carlsbad  water  in  ulcer  of  the  stomach  is  now  much  more  readily 
understood,  since  we  know  that  the  ulcer  is  in  many  cases  accom- 
panied by  hyperacidity,  and  that  the  mineral  water  not  alone  mo- 
mentarily neutralizes  this  (just  as  in  cases  of  hypersecretion),  but 
also  that  it  may  actually  lessen  the  activity  of  the  secretion.  A 
similar  effect  might  also  be  produced  by  the  purely  alkaline  waters, 
but  they  have  not  yet  been  used  much  for  this  purpose.  Finally, 
the  sodium-sulphate  waters  are  to  be  used  in  those  cases  in  which 
the  stomach  is  only  secondarily  involved  from  disturbances  of  the 
liver  and  the  intestines. 

However,  the  saline  waters  are  indicated  in  all  cases  of  catarrh 
with  lessening  of  the  secretion,  either  with  or  without  the  produc- 
tion of  mucus.  Here  we  may  use  the  simple  sodium-chloride  wa- 
ters where  the  patient  is  otherwise  well,  and  only  the  gastric  and 
intestinal  secretions  are  to  be  augmented;  the  sparkling  sodium- 
chloride  Avaters  are  useful  where  we  desire  the  stimulating  effects 
of  the  carbonic-acid  gas,  and  where,  by  moderate  catharsis  and 
the  use  of  the  brine  as  such,  the  metabolism  may  be  increased. 
Finally,  all  Avaters  which  are  to  act  on  the  stomach  are  borne  better 
warm  than  cold. 

In  the  above  I  have  simply  given  the  general  indications  for 
choosing  springs ;  for  further  details  I  must  refer  you  to  the  text- 
books on  balneology,  and  to  the  admirable  treatise  of  Leichtenstern 
in  Ziemssen's  Handbuch  der  allgemeinen  Therapie.*  I  need  hardly 
tell  you  how  much  is  left  for  individualizing  by  noting  the  equip- 
ment of  the  different  resorts,  such  as  mud  and  iron  baths,  mild  effer- 
vescing iron  springs,  medico-mechanical  [for  instance,  like  Zanders 
system]  and  electrical  treatment,  etc.     These  details  must  be  attended 

*  [Vol.  IV  of  American  translation,  New  York,  1885.— Te.] 


TREATMENT  OP   CHRONIC   GASTRITIS.  361 

to,  lest  a  stereotyped  method  of  treatment  be  employed,  and  that 
the  individual  indications  may  be  projDerly  looked  after ;  in  other 
words,  the  treatment  must  be  adapted  to  the  patient,  not  the  pa- 
tient to  the  treatment. 

It  is  unquestionable  that  the  treatment  will  be  much  more  suc- 
cessful if  the  diagnosis  of  gastric  catarrh  is  exactly  defined  into  one 
of  the  three  varieties — simple,  mucous,  or  atrophic  catarrhal  gas- 
tritis. This  can  only  be  done  by  employing  the  chemical  methods, 
the  use  and  success  of  which  have  been  greatest  in  this  field  where 
they  were  at  first  least  expected. 

Finally,  it  is  of  equal  importance  to  both  physician  and  patient 
that  in  the  selection  of  a  suitable  watering-place  for  the  latter,  the 
former  should,  if  possible,  know  the  place  recommended  from  his 
own  personal  observation.  Here,  again,  we  must  individualize,  for 
even  if  the  analyses  of  two  mineral  springs  are  almost  identical,  yet 
it  does  not  therefore  follow  that  they  are  equally  well  adapted  to 
the  same  class  of  patients.  The  other  adjuvants  of  the  place  must 
be  considered,  and  to  know  the  character  of  the  physician  to  Avhom 
we  intrust  our  patients  is  not  unimportant, 

[Addendum  to  p.  343. — Three  cases  of  poisoning  from  leaving  antiseptic  solu- 
tions in  the  stomach  are  reported  in  W.  Soltau  Fenwiek's  paper,  On  some  of  the 
Dangers  of  washing  out  the  Stomach,  which  appeared  in  the  Practitioner,  1892, 
No.  4,  after  these  pages  had  gone  through  the  press.  In  one  of  these  cases  (Schmidt's 
Jahrbiichcr,  1883,  Bd.  cxcviii,  S.  28)  death  resulted  in  six  days  after  leaving  a  2-to- 
3-per-cent  solution  of  boric  acid  in  the  stomach. 

Fenwick  also  makes  a  strong  plea  against  the  indiscriminate  and  unnecessary 
use  of  the  stomach-tube,  especially  where  its  employment  is  not  indicated.  He 
urges  that  more  care  be  taken  in  filling  and  emptying  the  stomach,  lest  syncope  and 
sudden  death  occur  from  changing  pressure  on  the  great  abdominal  plexuses  of  the 
sympathetic.  lie  also  protests  against  assuming  that  we  are  always  dealing  with 
normal  tissues.  The  not  infrequent  occurrence  of  tetany  after  lavage,  twenty-three 
cases  of  which  have  been  reported  (twenty-one  are  collected  in  Bouvret  and  Devic 
[Revue  de  med.,  February,  1892]),  with  a  mortality  of  72  per  cent,  should  also  serve 
as  a  warning.  These  cases,  together  with  those  on  pp.  84  and  85,  indicate  caution. 
But  this  is  true  of  every  exploratory  procedure,  and,  when  the  number  of  accidents 
is  compared  with  the  innumerable  times  the  tube  is  passed  safely,  it  becomes  quite 
insignificant.    Nevertheless,  Fenwiek's  warning  ought  not  to  be  disregarded. — Tr.] 


LECTUEE  IX.       . 

THE    NEUROSES    OF   THE    STOMACH. — THE    PHYSIOLOGICAL    RELATIONS    OF 

THE    STOMACH. 

Gentlemen  :  The  term  neuroses  of  the  stomach  includes  all 
those  conditions  which  manifest  themselves  as  disturbances  of  diges- 
tion without  demonstrable  anatomical  lesion  in  that  organ ;  or,  if 
such  be  present,  they  are  only  secondary  ;  in  other  words,  the  neu- 
roses of  the  stomach  are  ihe functional  disturbances  as  opposed  to 
the  so-called  organic. 

Our  knowledge  of  this  subject  is  by  no  means  recent ;  for  exam- 
ple, you  will  find  a  description  which  was  excellent  for  the  time  in 
which  it  was  written,  by  Comparetti  (1Y90).*  Since  then  many  writers 
have  been  engaged  on  this  theme,  especially  the  French  and  Eng- 
lish, including  Barras,  Beau,  Trousseau,  Chambers,  Budd,  Fother- 
gill,  Fenwick,  and  others.  Yet  since  then  great  advances  have  been 
made  as  the  result  of  the  labors  of  investigators  in  every  land,  and 
in  Germany  especially  by  the  work  of  Leube.  It  must  be  admitted 
that  our  knowledge  is  chiefly  of  a  descriptive  nature,  and  that  the 
etiology  of  the  disturbances  is  far  from  being  thoroughly  under- 
stood. However,  if  we  remember  that  the  stomach  is  the  center  of 
a  far-reaching  plexus  whose  cerebral  and  sympathetic  fibers  have 
man}'-  anastomoses,  with  the  resulting  crossing  and  mingling  of  both 
stimulating  and  inhibitory  impulses,  it  will  be  easily  understood 
how  difficult  it  is  to  bring  order  out  of  this  chaos,  and  to  isolate  the 
separate  threads  of  this  entangled  meshwork.  It  will  also  become 
evident  why  writers,  among  whom  we  may  mention  Stiller,  Rosen- 
thal, and  Oser,f  have  endeavored  to  establish  the  manifold  manifes- 

*  Occursus  medici  de  vaga  segritudine  infirmitatis  nervorum  Andreje  Com- 
paretti.   Venetiis,  1790. 

\  Stiller.    Die  nervosen  Magenkrankheiten.     Stuttgart,  1884. — Rosenthal.     Ma- 

(362) 


INNERVATION   OP   THE  STOMACH.  363 

tations  of  the  disturbed  innervation  of  tlie  organ  upon  a  basis  cor- 
responding to  our  present  knowledge  of  its  pliysiology.  Yet  even 
to  this  day  our  knowledge  is  so  limited  and  vague  that  conjecture 
and  hypothesis  still  play  a  prominent  part,  while  the  actual  clinical 
facts  upon  which  our  pathology  is  based  fill  only  a  very  small  space. 
How  easil}^,  then,  can  we  speculate  as  to  the  probable  causes  and 
refer  everything  to  higher  centers  of  innervation — e.  g.,  Rosenthal's 
hunger-center,  for  which  we  may  bring  as  many  arguments  jpro 
as  contra  !  I  shall  therefore  refrain  from  such  discussions  in  the 
following  pages  ;  instead,  I  shall  give  you  what  I  think  will  be  a 
welcome  basis  for  any  reflections  of  this  kind  by  prefacing  a  chap- 
ter on  what  we  know  of  the  innervation  of  the  stomach,  and  of  the 
general  sensations  proceeding  from  it — i.  e.,  the  pathology  of  the 
neuroses. 

My  brother,  Dr.  R,  Ewald,  Professor  of  Physiology  at  Stras- 
burg,  has  w^ritten  the  following  chapter  at  my  request,  and  for  this  I 
desire  to  give  him  my  heartiest  thanks. 

THE   INNERVATION   OF   THE    STOMACH. 

It  was  an  epoch-making  advance  when  the  old  vital  forces  were 
dethroned  and  only  physical  manifestations  were  allowed  to  explain 
the  operations  of  the  organism.  The  physical  methods  of  research 
were  adopted  and  the  vital  processes  were  placed  on  a  correspond- 
ing basis.  This  was  the  first  step  which  absolved  physiology  from 
its  long  bondage  as  a  subordinate  part  of  anatomy  and  elevated  it  to 
an  independent  science.  But  the  fond  hopes  which  were  placed  on 
purely  physical  explanations  even  "up  to  a  few  decades  ago  have 
since  been  proved  to  be  unattainable,  and  the  inevitable  reaction  has 
set  in  after  we  had  in  vain  waited  for  the  solution  of  all  problems 
by  physical  science.  Even  some  of  the  most  enthusiastic  investi- 
gators who  had  placed  implicit  faith  in  these  explanations  now 
ceased  to  blindly  follow  this  alluring  path.  Not  that  there  was  a 
reaction  to  the  old  vital  forces  ;  not  that  every  attempt  at  an  expla- 
nation was  rejected  in  despair  ;  but  experimenters  became  convinced 


genneurosen  und  Magenkatarrh.    Wien,  1886. — Oser.     Die  Neurosen  des  Magens 
und  ihre  Behandlung.    Wiener  Klinik,  1885. 


364  DISEASES  OP  THE  STOMACH. 

that  in  many,  in  fact  in  nearly  all  the  better  known  phenomena  the 
physical  laws  did  not  suffice  to  give  a  clear  explanation  of  the  mys- 
terious vital  phenomena.  Unfortunately,  we  are  now  nearly  every- 
where compelled  to  assume  a  specific  yet  absolutely  unknown 
activity  of  the  living  cell.  This  reaction  was  very  beneficial ;  it 
unmasked  an  apparent  knowledge  and  brought  us  nearer  to  a  true 
understanding  of  ISTature  ;  and,  even  if  we  must  finally  admit  a  me- 
chanical basis,  yet  we  are  still  infinitely  remote  from  the  goal  of  all 
natural  science.  That  we  can  only  reach  this  goal  by  extending 
our  knowledge  of  the  vital  phenomena  in  the  individual  cells  is 
the  advance  which  has  resulted  from  the  reaction  against  purely 
physical  speculations.  The  same  conceptions  which  elevated  physi- 
ology to  an  indej^endent  science  would  merely  have  converted  it 
into  physics  and  chemistry  as  applied  to  vital  phenomena.  ]^ow, 
however,  its  character  as  an  independent  science  is  forever  pre- 
served. 

The  General  Relations  of  the  Functions  of  the  Stomach  and  the 
Nervous  System. — The  functions  of  the  stomach  consist  mainly  of 
secretion,  absor]3tion,  and  motion.  It  was  once  thought  that  the 
activity  of  the  glands  could  be  explained  by  the  purely  mechanical 
processes  of  filtration  and  diffusion.  The  chemical  and  physical 
changes  in  the  blood  circulating  about  the  glands,  of  which  the  phys- 
ical were  regulated  by  the  nerves,  seemed  sufficient  to  explain  why 
the  secretion  of  one  and  the  same  gland  may  vary  in  strength  and 
composition. 

Although  Johannes  Miiller  had  long  ago  called  attention  to  the 
specific  activity  of  the  glandular  cells,  yet  only  recently  w^as  it  posi- 
tively demonstrated  that  the  mechanical  processes  of  filtration  and 
diffusion  do  not  suffice  to  explain  secretion,  and  that  we  must  accept 
the  existence  of  a  peculiar  activity  of  the  cells.*  ISTerves  may  regu- 
late this  cellular  activity,  yet  secretion  is  unquestionably  possible 
without  them,  and  in  this  respect  the  animal  tissues  do  not  differ 
from  the  vegetable,  which  have  glands  but  no  nerves. 

In  the  process  of  absorption  the  specific  activity  of  the  indi- 
vidual cells  becomes  even  more  obvious.    Here,  contrary  to  physical 

*  Ewald.     Klinik,  etc.,  I.  Theil,  3.  Auflage,  S.  61  und  208  et  seq. 


GENERAL  RELATIONS  OF   THE  STOMACH.  365 

laws,  some  substances  are  taken  up,  while  others  are  rejected.  The 
lymph-cells  have  been  observed  to  wander  to  the  surface  of  the  in- 
testinal mucous  membrane,  and  there  incorporate  drops  of  fat ;  they 
then  creej)  back  even  into  the  lacteals,  where  they  give  up  these  par- 
ticles of  fat.  In  the  face  of  such  occurrences,  which  seem  to  play 
an  important  part  in  absorption,  how  can  we  think  of  purely  me- 
chanical explanations  ?  At  all  events,  in  the  processes  of  absorption 
peculiar  functions  of  the  living  cells  must  coexist  with  filtration  and 
diffusion. 

The  conditions  are  no  more  favorable  in  the  motor  function.  I 
disregard  entirely  the  fact  that  what  occurs  in  a  muscle  during  con- 
traction is  as  incomprehensible  as  what  constitutes  innervation  in  a 
nerve.  But  the  dependence  of  the  contraction  upon  the  nervous 
impulse,  and  the  invariable  result  of  this  impulse,  namely,  a  shorten- 
ing of  the  muscle,  were  formerly  regarded  as  a  general  and,  in  a 
certain  sense,  physical  law.  Indeed,  for  striped  muscle  it  would  be 
difficult  to  find  an  exception  to  this  law,  if  we  do  not  include  the 
direct  stimulation  of  the  muscle  which  can  only  occur  in  an  ab- 
normal way.  The  striped  muscle-fiber  is  always  at  rest  till  an  im- 
pulse reaches  it  through  its  nerve ;  the  result  of  this  impulse  is  al- 
ways a  contraction,  be  it  a  jerk  or  tetanus.  The  apparent  exception 
that  the  heart  continues  to  beat  even  after  all  its  nerves  have  been 
divided,  was  explained  by  assuming  that  the  impulses  may  arise  in 
the  heart  itself  in  its  ganglion-cells,  and  that  these  impulses  are 
transmitted  to  the  cardiac  muscle-fibers  through  the  intracardiac 
nerves.  It  was,  however,  discovered  that  sections  of  the  heart 
which  positively  contained  no  ganglion-cells  continued  to  beat  rhyth- 
mically. The  greatest  difficulty  of  maintaining  the  law  of  the  de- 
pendence of  muscular  contraction  upon  nervous  impulses  is  encount- 
ered in  the  unstriated  muscles.  Here  w^e  not  alone  observe  move- 
ments which  are  independent  of  any  nervous  influence,  as  for  exam- 
ple in  the  ureter,  but  we  are  not  even  able  in  every  instance  to 
prove  that  the  result  of  the  nervous  impulse  is  a  contraction  of  the 
muscle.  Thus  irritation  of  the  vaso-dilator  nerves  causes  the  arte- 
rioles to  relax,  and  as,  for  many  reasons,  we  can  not  explain  this  by 
the  longitudinal  fibers,  we  are  compelled  to  assume  the  paradox  that 
the  circular  fibers  lengthen  upon  irritation.     We  must  therefore 


366  DISEASES  OP  THE  STOMACH. 

admit  tliat,  with  tlie  possible  exception  of  the  striated  muscles,  the 
above  law  does  not  always  operate,  and  that  consequently  the  mus- 
cles may  both  make  spontaneous  movements,  and  may  also  lengthen 
uj)on  stimulation. 

These  preliminary  remarks  will  enable  us  to  comprehend  more 
readily  the  unpleasant  fact  that  we  know  very  little  about  the  secre- 
tion, absorption,  and  motility  of  the  stomach.  The  experiments  are 
very  frequently  contradictory  ;  many  contain  conditions  which,  upon 
closer  examination,  preclude  a  uniform  result.  It  is  evident  that  the 
study  of  the  organ  has  been  undertaken  with  too  many  physical 
propositions,  whereas  here,  as  in  the  entire  digestive  tract,  biological 
laws  are  more  important.  It  seems  that  the  more  highly  vegetative 
the  functions  of  an  organ  are,  the  more  does  its  activity  depend 
upon  its  own  cells,  and  the  less  upon  the  nervous  system.  In  fact, 
could  we  remove  every  nervous  element,  nerve-fibers  as  well  as  gan- 
glia, from  the  walls  of  the  stomach  without  injuring  the  other  tissues, 
it  would  still  secrete,  absorb,  and  contract  quite  well.  One  may  ask. 
Why,  then,  all  these  nerve-fibers  which  enter  the  stomach  ?  For  the 
same  reason  that  nerves  go  to  the  automatic  heart — to  connect  it 
with  the  rest  of  the  body.  On  the  one  hand,  the  stomach  has  these 
connections  with  the  central  nervous  system  to  fulfill  the  demands  of 
the  other  parts  of  the  body ;  and,  on  the  other,  to  enable  the  entire 
organism  to  take  cognizance  of  its  conditioa. 

Anatomy  of  the  Nerves  of  the  Stomacli. — The  Vagus  Nerve. — 
Below  the  neck  both  pneumogastrics  travel  along  the  oesophagus, 
the  left  or  the  smaller  being  on  its  anterior  aspect,  the  right  or  the 
larger  on  its  posterior ;  they  maintain  the  same  relation  in  passing 
through  the  diaphragm.  But  these  are  not  the  only  fibers  of  the 
vagi  which  reach  the  stomach,  for  as  soon  as  the  nerves  reach  the 
CBSophagus  they  give  off  numerous  small  filaments  which  form  a 
delicate  plexus,  invisible  to  [the  naked  eye  of]  experimenters,  in  the 
substance  of  the  oesophagus  and  thus  reach  the  stomach.  Hence  it 
will  not  suffice  to  simply  divide  the  two  vagi  upon  the  oesophagus 
to  sever  their  connection  with  the  stomach  (Brachet),  but  a  circular 
incision  must  be  made  down  to  the  muscular  layer  in  the  oesophagus 
just  below  the  diaphragm  (Schiff).  The  left  nerve  passes  from  the 
anterior  surface  of  the  oesophagus  to  the  cardia  and  lesser  curvature, 


ANATOMY   OP  THE  NERVES  OP  THE  STOMACH.  367 

forms  the  anterior  gastric  plexus,  and  divides  into  terminal  fila- 
ments, wliicli  proceed  along  the  anterior  surface  of  the  stomach  as 
far  as  the  pylorus,  and  form  many  anastomoses  with  the  sympa- 
thetic. Two  thirds  of  the  right  nerve  pass  to  the  abdominal 
organs  and  only  one  third  reaches  the  posterior  surface  of  the 
stomach,  where  it  forms  the  j)osterior  gastric  plexus.  The  terminal 
filaments  radiate  from  this  over  the  posterior  surface,  and,  like 
those  of  the  left  nerve,  form  numerous  anastomoses  with  the  sym- 
pathetic. 

The  SynijpatlietiG  Nerves. — From  the  coeliac  plexus,  the  cerebrum 
abdominale  of  the  ancients,  in  the  formation  of  which  the  vagi, 
especially  the  right,  participate,  is  developed  a  series  of  secondary 
plexuses.  Among  these  is  the  coronary  plexus  (plexus  coronarius 
ventriculi  azygos),  which  accompanies  the  left  coronary  [gastric]  ar- 
tery of  the  stomach  to  the  lesser  curvature,  and  communicates  with 
the  two  plexuses  of  the  vagi.  Another  secondary  azygos  plexus  is 
the  hepatic,  which  is  also  partially  formed  by  the  pneumogastrics ; 
a  branch  of  this  plexus  accompanies  the  right  coronary  [pyloric] 
artery  of  tiie  stomach  to  the  lesser  curvature,  where  it  communi- 
cates with  the  coronary  plexus.  Another  somewhat  larger  branch 
of  the  same  plexus,  which  has  received  the  name  of  inferior  coro- 
nary ^ilexus  (plexus  coronarius  ventriculi  inferior),  passes  along  with 
the  right  gastro-epiploic  artery  to  the  greater  curvature  ;  communi- 
cating branches  to  the  plexus  of  the  vagi  are  also  given  off  by  this 
plexus. 

Ganglioii-Gells. — The  radicles  of  the  two  intestinal  plexuses  may 
be  traced  into  the  stomach ;  beginning  at  the  lesser  curvature,  the 
plexus  myentericus  has  already  developed  into  a  thick  network  at 
the  pylorus,  and  communicates  here  with  the  gastric  branches  of 
the  vagi  (Auerbacli).  The  plexus  submucosus  (Meissner's)  may  also 
be  demonstrated  even  at  the  pylorus ;  it  probably  contains  fewer 
ganglion-cells  than  Auerbach's  plexus,  just  as  is  the  case  in  the 
other  parts  of  the  intestines. 

Secretion. — In  spite  of  numerous  and  careful  experiments  in 
stimulating  and  dividing  the  nerves  communicating  with  the  stom- 
ach, no  definite  efliects  on  the  secretion  have  yet  been  produced. 
We  mio'ht  even  doubt  the  influence  of  these  nerves  on  the  secre- 


368  DISEASES  OF  THE  STOMACH. 

tion,  did  we  not  know  from  other  sources  tliat  botli  stimulating  and 
depressing  impulses  jDass  along  them  to  the  glands  of  the  stomach. 
The  most  important  observation  on  this  subject  was  made  bj  Eichet 
on  a  man  with  a  stricture  of  the  ossophagus  which  necessitated  the 
making  of  a  gastric  fistula.  It  was  positively  proved  that  the 
oesophagus  was  completely  occluded,  and  that  not  the  smallest  trace 
of  saliva  could  reach  the  stomach ;  by  asking  the  patient  to  chew 
some  ferrocyanide  of  potassium  not  a  trace  of  the  salt  could  be  de- 
tected in  the  stomach ;  yet  whenever  he  chewed  substances  with  a 
strong  taste  (sugar,  slices  of  lemon,  etc.)  there  was  always  a  copious 
secretion  in  the  stomach.  This  interesting  case  proves  that  the 
secretion  of  the  stomach  may  be  reflexly  stimulated  by  centers  lying 
outside  of  that  viscus ;  hence,  the  glands  of  the  stomach  are  inner- 
vated by  the  nerves  communicating  with  it.  Like  the  nerves  of 
taste,  the  olfactory  nerves  may  also  produce  this  reflex  directly- 
i.  e.,  without  the  intervention  of  a  psj-chical  process.  It  is  different 
when  the  reflex  proceeds  from  the  optic  nerve ;  thus,  the  mere  sight 
of  meat  causes  a  copious  secretion  of  gastric  juice  in  hungry  dogs, 
just  as  the  sa,liva  runs  freely  from  their  mouths  if  they  look  for  a 
long  time  at  a  lump  of  sugar.  However,  it  is  evident  that  the 
reflex  does  not  proceed  directly  from  the  optic  nerve,  but  that  the 
sight  of  the  food  first  produces  a  mental  impression,  and  this  it  is 
which  causes  the  secretion.  We  ourselves  all  know  that  we  need 
not  even  see  food,  but  that  simply  the  thought  of  savory  dishes 
"  makes  our  mouths  water."  It  will  not  be  erroneous  to  infer  that 
this  reflex  extends  also  to  the  stomach. 

The  secretion  of  the  stomach  may  be  reflexly  lessened  in  the 
same  way  as  it  may  be  stimulated.  The  taste,  smell,  sight,  and  even 
thought  of  disgusting  food  cause  such  inhibitions.  Usually  these 
various  reflexes,  whether  stimulating  or  depressing,  combine  and 
produce  a  more  marked  effect. 

Having  thus  seen  the  effects  of  visual  impressions  upon  the  gastric 
secretion,  it  becomes  evident  that  it  may  also  be  influenced  by  psy- 
chical processes ;  yet  this  connection  becomes  more  apparent  when 
we  consider  the  effects  produced.  Taken  all  in  all  their  action  is 
inhibitory ;  the  most  potent  of  all  is  the  influence  of  fear.  It  domi- 
nates the  entire  digestive  tract ;  it  causes  the  food  "  to  stick  in  the 


GASTRIC  SECRETION,  369 

throat "  on  account  of  the  stoppage  of  the  secretion  of  saliva  and 
the  refusal  of  the  muscles  of  deglutition  to  act.  Fear  may  cause 
involuntary  defecation  by  increasing  the  peristalsis  of  the  intes- 
tines.* In  the  cases  of  which  we  hear  that  fear  caused  the  food  to 
remain  undigested  in  the  stomach  for  hours  and  to  be  finally  vom- 
ited, we  will  not  err  in  assuming  that  this  is  due  to  an  absence  of 
the  necessary  gastric  juice,  corresi^onding  to  a  similar  lack  of  saliva ; 
it  can  not  be  due  to  an  increased  peristalsis  of  the  stomach,  since 
such  a  condition  would  favor  gastric  digestion. 

Although  it  is  beyond  doubt  that  both  stimulating  and  inhibi- 
tory impulses  are  conveyed  along  the  nerves  to  the  gastric  glands, 
yet  the  fact  nevertheless  remains  that  even  after  the  section  of  all 
these  nerves  the  secretion  does  not  cease  and  may  even  be  increased 
by  an  irritation  of  the  mucous  membrane.  It  is  not  improbable  that 
stimuli  pass  directly  or  indirectly  along  sensory  paths  to  the  gan- 
glion-cells in  the  wall  of  the  stomach,  and  that  from  these  the  glands 
are  stimulated  to  activity.  This  has  not  yet  been  proved,  and,  as 
Heidenhain  has  already  said,  we  can  not  disregard  the  fact  that 
these  stimuli  may  act  on  the  glandular  cells  directly  without  any 
nervous  intervention.  It  has  been  demonstrated  through  gastric 
fistulge  that  normally  even  the  contact  of  a  foreign  body  with  the 
mucous  membrane  causes  a  circumscribed  secretion  at  the  place 
touched.  Only  the  mechanical  stimulation  operates  in  such  a  case, 
since  the  same  effect  is  produced  by  a  pebble  or  by  lightlj^  applying 
a  feather.  The  amount  of  the  secretion  thus  produced  is  very 
small,  but  immediately  increases  and  loses  its  circumscribed  charac- 
ter if  absorption  of  even  innutritions  fluids  like  water  takes  place. 
But  the  entire  stomach  becomes  active  and  the  secretion  reaches  its 
normal  strength  only  when  the  organ  contains  absorbable  nutritious 
material.  It  is  by  no  means  essential  that  these  fluids  enter  the 
stomach  as  such,  but  the  liquids  produced  by  the  solution  and  diges- 
tion of  solid  food  will  suffice.  It  must  remain  an  open  question 
whether  this  absorbed  food  acts  indirectly  by  altering  the  blood,  or 

*  It  has  been  erroneously  supposed  that  defecation  results  from  tlie  relaxation 
of  the  sphincter.  But  the  rectum  is  normally  empty,  and  under  such  circumstances 
defecation  can  not  result  from  simple  opening  of  the  sphincter.  Hence  it  is  abso- 
lutely impossible  to  explain  in  this  way  the  diarrhoea  which  results  from  fear. 


370  DISEASES  OP   THE  STOMACH. 

directly  by  affecting  tlie  nervous  elements  in  tlie  stomach ;  yet  the 
reflex  character  of  this  stimulation  is  shown  by  its  extension  over 
the  entire  stomach.  We  must  therefore  assume  that  normally  the 
contact  of  food  with  the  mucous  membrane  causes  a  local  secretion 
which  is  possibly  j^roduced  by  a  direct  stimulation  of  the  glands, 
and  that  at  the  same  time  the  absorption  of  food  reflexly  calls  the 
entire  secretory  apparatus  of  the  organ  into  activity. 

Absorption. — A  not  insignificant  portion  of  the  food,  both  fluid 
and  that  liquefied  in  the  stomach,  is  absorbed  by  the  stomach  itself. 
As  the  walls  of  the  vessels  and  the  surrounding  portions  of  the 
stomach  constitute  an  animal  membrane,  filtration  and  osmosis  may 
play  an  important  part.  This  explanation  of  absorption  appears  all 
the  more  acceptable  because  variations  in  this  process  which  are 
believed  to  be  of  nervous  origin  may  easily  be  attributed  to  vaso- 
motor changes  in  the  blood,  and  even  the  lymph-vessels.  Absorp- 
tion is  also  directly  influenced  by  the  nervous  system.  The  first 
decisive  experiment  on  this  subject  was  made  by  Goltz  ;  it  may  be 
briefly  described  as  follows  :  In  two  frogs  the  heart  was  removed, 
thereby  rendering  circulation  impossible ;  then  the  brain  and  spinal 
cord  of  one  of  these  frogs  were  destroyed,  in  the  other  they  were 
left  intact.  An  equal  amount  of  a  strychnine  solution  was  then 
injected  under  the  skin  of  the  hind  leg  of  each  of  them ;  after  a 
time  it  could  be  demonstrated  that  the  fore  leg  of  the  frog  with  the 
intact  central  nervous  system  contained  strychnine  and  was  poisonous 
when  some  of  its  juices  were  injected  into  another  frog  ;  but  the  fore 
leg  was  not  poisonous  in  the  frog  without  "'ts  central  nervous  system, 
and  hence  contained  none  of  the  alkaloid.  As  there  was  no  circula- 
tion of  either  blood  or  lymph,  the  strychnine  must  have  passed 
from  the  hind  leg  to  the  fore  leg  by  diffusion,  or,  if  we  wish  to  avoid 
the  use  of  this  strictly  physical  expression,  by  absorption.  The 
experiment  therefore  proves  that  the  rapidity  of  this  absorption  was 
influenced  by  the  nervous  system. 

How  shall  we  think  of  this  influence  ?  Certainly  not  from  a 
purely  physical  standpoint,  as  if  the  nerves  had  altered  the  texture 
of  the  parts  of  Ihe  body  involved,  and  in  this  way  changed  the  ra- 
pidity of  diffusion,  just  as  a  tense  membrane  affects  filtration  and  dif- 
fusion differently  than  a  relaxed  one.    We  would  rather  assume  that 


VASO-MOTOR  NERVES  OF  THE  STOMACH.  371 

tlie  activity  of  the  individual  living  cells  had  been  altered,  causing 
them  to  absorb  and  give  up  the  strjclmine  solution  to  the  neighbor- 
ing cells  more  rapidly.  The  existence  of  an  independent  activity  of 
the  living  cells  ought  not  to  surprise  us  if  we  recall  the  remarkable 
functions  of  the  white  blood-cells  mentioned  on  page  365,  or  if  we 
remember  that  some  one-celled  animalcules  only  choose  certain  algae 
for  their  food. 

Absorption  may  thus  take  place  very  easily  in  the  stomach  with- 
out any  influence  of  the  nervous  system  through  the  individual  ac- 
tivity of  the  cells  of  the  mucous  membrane,  and  of  the  walls  of 
the  vessels,  and  even  of  the  blood  itself.  It  may  be  changed  by 
tiie  nervous  system  both  quantitatively  and  qualitatively.  It  is 
also,  to  some  extent,  affected  by  the  physical  laws  of  filtration  and 
diffusion,  which  in  turn  are  influenced  by  chemical  and  physical 
changes  in  the  circulation  But  the  physical  relations  of  the  circu- 
lation are  regulated  by  a  direct  nervous  influence,  and  in  this  way 
the  nervous  system  may  exert  a  double  regulating  action  on  absorp- 
tion. The  paths  of  the  direct  nervous  regulation  of  the  cell  activity 
are  still  absolutely  unknown.  I  will  now  discuss  those  which  in- 
fluence the  circulation  of  the  blood. 

Vaso-motor  Nerves. — Whenever  the  glands  of  a  part  or  of  the 
whole  stomach  are  in  active  secretion  it  is  constantly  observed  that 
the  secreting  area  has  an  increased  blood-supply.  The  arteries  dilate, 
the  blood  flows  more  rapidly,  and  reaches  the  veins  in  a  less  oxidized 
condition.  The  object  of  this  heightened  circulation  is  manifestly 
to  bring  a  sufficient  amount  of  material  for  secretion.  These  changes 
may  be  recognized  by  the  reddening  of  the  mucous  membrane  and  a 
marked  turgescence  and  erection  of  its  folds,  especially  of  the  large 
ones  near  the  pylorus. 

How  does  this  vascular  dilatation  occur  ?    The  vaso-motor  nerves 

may  be  stimulated  directly — i.  e.,  either  by  mechanical  irritation 

produced  by  the  weight  of  the  ingesta,  or  by  their  rubbing  against 

the  walls  of  the  stomach  and  the  like,  or  by  a  chemical  stimulation 

proceeding  from  the  absorbed  materials.     The  extent  of  the  area  of 

dilatation  would  thus  correspond  to  the  area  to  which  the  directly 

stimulated  nerves  are  distributed.     But  the  irritation  of  the  mucous 

membrane  with  a  feather  or  a  solid  body  only  produces  a  local  red- 
24 


372  DISEASES  OF  THE  STOMACH, 

dening  corresponding  to  the  irritated  area.  This  would  indicate  an 
immediate  influence  on  the  walls  of  the  vessels  themselves,  and  ren- 
ders the  above-described  transfer  of  the  stimulation  to  the  vaso- 
motor nerves  very  improbable.  A  similar  and  even  more  localized 
reddening  may  be  produced  in  the  skin  by  rubbing  or  drawing  a 
line  on  it ;  chemical  irritants  (stimulating  plasters)  also  exert  a  local 
action.  These  manifestations  are  undoubtedly  due  to  a  local  action 
on  the  vascular  walls ;  and  the  same  seems  to  be  true  of  the  stomach. 
Let  it,  however,  not  be  understood  that  an  important  part  may  not 
be  j)layed  by  the  true  vascular  reflex  which  follows  mechanical, 
chemical,  and  thermal  stimulation,  proceeds  along  the  sensory  nerves 
and  acts  through  the  medullary  and  spinal  centers  (Schmidt-Miihl- 
heim)  upon  the  vascular  nerves.  For  we  also  know  that  holding  a 
piece  of  bacon  before  a  hungry  dog  causes  an  increase  in  the  tem- 
perature of  the  stomach  which  is  analogous  to  the  heightened  secre- 
tion. Possibly  the  same  influences  operate  here  as  in  secretion. 
The  reflex  stimuli  are  probably  associated  with  the  direct  local  ones, 
but  they  differ  from  the  latter  by  influencing  the  stomach  in  its  en- 
tire extent. 

We  are  justifled  in  assuming  that  the  path  of  the  vaso-motor  im- 
pulses is  along  the  sympathetic  nerves.  This  is  rendered  probable 
by  the  analogical  conditions  in  other  parts  of  the  body  as  well  as  by 
the  fact  that  very  moderate  vascular  changes  follow  the  division  of 
the  vagi,  Yaso-constrictor  nerves  probably  accompany  the  vaso- 
dilators everywhere ;  this  may  explain  why  in  all  the  experiments  to 
demonstrate  the  relations  of  the  stomach  to  the  nervous  system  not 
alone  the  various  experimenters  have  differed  so  among  themselves, 
but  also  the  same  observer  has  obtained  such  contradictory  results 
on  repeating  the  same  experiment.  The  manifold  functions  of  the 
nerves  distributed  to  the  stomach  are  indicated  by  their  size  ;  and  we 
also  have  many  undoubted  proofs  of  centrifugal  impulses  in  the 
effects  of  fear,  in  the  case  of  Eichet  (p.  368),  and  in  other  similar 
observations.  Bat  why  is  the  result  so  often  absent  on  stimulating 
the  vagus  and  sympathetic  ?  Why  do  we  get  one  result  in  some 
cases  and  the  contrary  in  others  ?  I  think  that  these  differences  are 
not  to  be  attributed  to  the  longer  or  shorter  interval  after  the  last 
meal,  to  the  various  degrees  of  fear  in  the  animals,  or  to  the  dif- 


THE  MOVEMENTS  OP  THE  STOMACH.  373 

ferent  aneestlietics.  In  my  judgment  the  probable  explanation  is  as 
follows : 

If  tlie  vagus  is  stimulated,  tlie  inhibitory  efEect  on  the  heart  is  so 
marked  that  for  a  long  time  the  presence  of  accelerating  fibers  was 
denied.  Had  the  effect  of  the  accelerating  fibers  exceeded  that  of 
the  inhibitory,  then  probably  the  former  would  only  have  been  rec- 
ognized at  first.  "What  would  be  the  result  if  both  sets  of  fibers 
were  equally  powerful  ?  Stimulation  of  the  vagus  might  then  be 
followed  by  inhibition  at  one  time,  by  acceleration  at  another,  or  by 
no  effect  at  all.  Where  the  stimulation  of  both  sets  of  fibers  is  ex- 
actly equal,  the  result  will  be  negative.  But,  on  the  other  hand, 
slight  variations  in  the  point  of  application  of  the  electrodes,  differ- 
ent conditions  of  exhaustion  of  the  various  groups  of  fibers,  and  the 
like,  may  cause  the  result  to  be  positive.  The  condition  of  the  heart, 
the  organ  supplied  by  the  nerve,  will  also  influence  the  result.  This 
is  well  shown  in  the  experiment  in  which  the  sciatic  nerve  of  a  dog 
is  stimulated  :  if  the  blood-vessels  of  the  paw  have  been  dilated  by 
heat,  the  irritation  will  cause  them  to  contract ;  but,  if  they  have 
been  contracted  by  cold,  then  a  dilatation  will  be  the  result.  Let  us, 
then,  suppose  that  all  the  inhibitory  and  stimulating  nerves  of  the 
stomach  are  acting  equally  powerfully ;  then  an  explanation  would 
be  given  why  strong  impulses  may  pass  along  the  vagus  and  sympa- 
thetic during  life,  and  yet  the  functions  of  these  nerves  may  remain 
unexplained  by  our  present  methods  of  investigation. 

The  Movements  of  the  Stomach. — When  spontaneous  movements 
are  observed  in  an  excised  organ  we  very  frequently,  but  not  always, 
find  ganglion-cells  in  these  tissues ;  hence  we  are  led  to  infer  that 
these  movements  depend  upon  the  ganglion-cells.  In  support  of 
this  view  I  may  mention  the  active  peristaltic  movements  of  an 
excised  piece  of  intestine ;  here  we  have  the  ganglion-cells  of 
Meissner's  and  of  Auerbach's  plexuses.  The  oesophagus  executes 
spontaneous  movements  twenty-six  hours  after  excision,  and  here, 
too,  numerous  ganglion-cells  may  be  found  in  its  walls. 

The  conditions  in  the  stomach  are  exactly  the  same,  for  it,  too, 
manifests  spontaneous  movements  a  long  time  after  removal  froni 
the  body,  and  in  its  walls  may  be  found  the  collections  of  ganglion- 
cells  already  described  (p.  368).     These  movements  differ  from  those 


374  DISEASES  OP  THE  STOMACH. 

normally  observed  in  being  less  regular  in  their  direction.  The 
peristaltic  and  the  antiperistaltic  movements  seem  to  alternate  ir- 
regularly, or  both  may  affect  various  parts  of  the  stomach  at  the 
same  time.  I*N^ormally,  by  means  of  fistulas  or  by  a  very  careful 
exposure  of  the  organ,  two  distinct  varieties  of  movements  have 
been  observed,  those  of  the  empty  viscus  and  those  during  diges- 
tion. In  the  former  condition  the  contractions  are  slower,  less  fre- 
quent, and  individually  less  energetic — i.  e.,  the  constrictions  are 
not  so  deep.  On  the  contrary,  while  secreting  they  are  rapidly 
executed,  much  more  frequent  in  occurrence,  and  each  contraction 
is  more  vigorous. 

A  great  variety  of  movements  has  been  observed.  Most  of  the 
waves  seem  to  proceed  from  the  pylorus  antiperistaltically  to  the 
middle  of  the  stomach,  and  then  run  back  to  the  pylorus  as  peri- 
staltic waves.  This  origin  of  the  movements  would  seem  to  indicate 
that  most  of  the  ganglion-cells  are  situated  at  the  pylorus.  The 
other  half  of  the  stomach  also  shows  various  movements,  but  they 
are  less  easily  traced.  A  permanent  transverse  constriction  across 
the  middle  of  the  organ,  the  so-called  cravate  de  Suisse,"^  and 
many  similar  features  have  been  described,  but  I  will  not  enter  into 
further  details  concerning  them,  and  shall  simply  mention  two  im- 
portant circumstances :  First,  we  must  distinguish  between  move- 
ments of  the  ingesta  and  the  visible  movements  of  the  organ,  as 
they  by  no  means  coincide  with  each  other.  The  former  should  be 
such  that  the  food  makes  a  circuit  of  the  stomach  in  one  or  another 
direction.  Secondly,  at  no  time  is  the  peristaltic  motion  exclusively 
in  one  direction,  and  hence  it  is  impossible  to  determine  from  the 
outside  whether  or  not  the  chyme  is  forced  through  the  pylorus. 
Long  pauses  may  occur  in  the  movements  of  the  empty  as  well  as 
of  the  full  stomach  ;  they  are  most  marked  in  the  former  and  may 
continue  for  hours,  but  when  full  the  periods  of  repose  last  only  a 
few  minutes. 

Concerning  the  object  of  these  movements  I  may  premise  that, 
as  there  is  only  a  thin  layer  of  muscular  fibers,  the  amount  of  force 

*  [This  term  has  been  applied  to  '■  the  layer  of  oblique  muscular  fibers  which 
pass  from  behind  the  cardia  to  below  the  pylorus.  By  contracting  they  form  a 
continuous  canal  between  these  two  orifices,  separate  from  the  fundus." — Tr.] 


THE  MOVEMENTS  OF  THE  STOMACH.  375 

generated  must  be  small,  and  that  any  meclianical  trituration  or 
grinding  of  tlie  food  is  out  of  tlie  question.  Such  a  mechanism  is 
not  compatible  with  a  secretory  apparatus,  since  strong  pressure 
would  be  injurious.  Hence,  in  birds,  where  such  grinding  and 
crushing  take  place,  we  observe  that  this  is  done  in  a  separate  mus- 
cular stomach,  while  secretion  occurs  in  another  stomach  specially 
arranged  for  the  purpose.  Therefore,  in  mammals  the  movements 
of  the  stomach  can  only  serve  the  twofold  purjjose  :  first,  to  move 
the  ingesta  about  so  that  they  may  be  brought  into  thorough  con- 
tact with  the  gastric  juice,  and  to  stimulate  the  secretion  of  the  lat- 
ter by  this  mechanical  irritation  of  the  walls  of  the  organ ;  and,  sec- 
ondly, to  expel  the  chyme. 

The  origin  and  insertion  of  the  muscular  fibers  at  the  cardia  and 
pylorus  are  arranged  in  a  special  manner,  and  also  have  special 
functions.  While  there  is  very  little  agreement  as  to  the  functions 
of  these  sphincters,  yet  the  following  facts  may  be  accepted:  Both 
orifices  are  normally  kept  lightly  closed  by  the  tone  of  the  sphinc- 
ters. The  opening  of  the  cardia  constitutes  the  last  part  in  the  act 
of  deglutition.  On  introducing  the  finger  into  the  cardia  from 
within  the  stomach,  rhythmical  contractions  may  be  felt  like  those 
of  the  sphincter  ani  after  section  of  the  spinal  cord.  Yet  there  is 
no  rhythmical  opening  of  the  oesophagus,  for  this  would  permit  the 
regurgitation  of  food ;  it  is  simply  a  "wandering  up  and  down"  of 
the  closed  orifice  of  the  stomach,  for  as  the  cardia  relaxes  the  former 
closes.  At  the  same  time  there  may  also  be  an  active  opening  of 
the  cardia  by  muscular  contractions  through  the  shortening  of  the 
muscular  fibers  passing  from  it  to  the  stomach.  The  pylorus  not 
possessing  such  bands  of  muscular  fibers  must  always  open  j)as- 
sively.  This  occurs  during  the  later  stages  of  gastric  digestion, 
partly  as  a  result  of  the  increased  pressure  exerted  on  it  by  the  food 
through  the  heightened  peristalsis,  and  also  partly  on  account  of  the 
increased  amount  of  hydrochloric  acid  in  the  chyme.  The  latter 
does  not  all  pass  into  the  duodenum  at  once,  but  intermittently ; 
this  may  be  due  to  the  fact  that  the  pylorus  has  rhythmical  move- 
ments like  those  of  the  cardia. 

As  already  mentioned,  section  of  all  the  nerves  distributed  to  the 
stomach  does  not  cause  the  cessation  of  all  its  various  movements. 


376  DISEASES  OP  THE  STOMACH. 

but  only  weakens  them,  and  abolishes  the  slight  degree  of  regularity 
and  co-ordination  which  they  had  previously  manifested.  In  mam- 
mals stimulation  of  the  vagus  usually  causes  peristaltic  movements 
of  the  organ  or  intensifies  those  already  present.  As  a  rule,  the 
pylorus  also  contracts  powerfully,  but  a  coincident  contraction  of 
some  duration  has  not  always  been  observed.  The  majority  of  ex- 
perimenters believe  that  similar  but  far  less  powerful  movements 
follow  stimulation  of  the  sympathetic.  On  the  other  hand,  stimula- 
tion of  the  splanchnic  nerves  in  the  abdominal  cavity  is  said  to  stop 
the  spontaneous  contractions  of  the  jDylorus  (Oser). 

Yet  all  these  experimental  stimulations  in  mammals  have  an  in- 
definite and  uncertain  character ;  their  success  is  usually  not  great 
and  by  no  means  constant.*  We  know  only  of  the  absolutely  clear 
and  satisfactory  experiment  on  frogs,  and  it  may  indeed  be  said 
that  it  is  the  only  positive  experiment  on  the  influence  of  the  nerves 
upon  the  movements  of  the  stomach.  I  refer  to  Goltz's  crucial  test 
with  curarized  frogs.f  In  spite  of  Goltz^s  warning  this  experi- 
ment is  nearly  always  falsely  interpreted.  The  main  point  at  issue 
is  really  a  stimulation  which  results  from  destroying  the  brain  and 
cord,  and  which  reaches  the  stomach  through  the  vagi.  The  same 
effect  may,  therefore,  be  obtained  by  laying  this  nerve  bare  and 
stimulating  it. 

Vomiting. — Magendie  thought  that  vomiting  was  exclusively  due 
to  the  action  of  the  abdominal  pressure,  which  is  entirely  independ- 
ent of  tlie  stomach.  As  is  known,  he  replaced  this  viscus  with  a 
pig's  bladder,  and  caused  the  exj)ulsion  of  its  contents  by  injecting 


*  There  is  no  lack  of  recent  positive  assertions,  but  confirmation  is  still  wanting; 
for  example,  see  the  review  of  R.  Kobert  in  Schmidt's  Jahrbiicher,  Bd.  211,  S.  244 ; 
and  Bd.  215,  S.  12. 

\  Vide  Ewald.  Klinik,  etc.,  I.  Theil,  3.  Auflage,  S.  7G.  [In  brief,  the  experi- 
ment is  as  follows :  Two  frogs,  whose  oesophagi  and  stomachs  have  been  laid  bare, 
are  suspended  vertically  after  having  been  curarized ;  in  addition,  in  the  one  frog 
the  brain  and  spinal  cord  have  been  destroyed.  A  dilute  solution  of  common  salt 
is  now  poured,  drop  by  drop,  into  their  mouths :  in  the  normal  frog  the  stomach 
and  ceeophagus  are  distended  and  full  of  fluid,  almost  motionless,  with  only  an  oc- 
casional peristaltic  wave,  and  look  just  like  a  distended  pig's  bladder ;  in  the  frog 
without  the  central  nervous  system  the  gullet  and  stomach  are  empty,  with  active 
peristaltic  waves  from  above  downward,  and  look  like  a  rosary.  The  same  results 
are  obtained  by  dividing  the  vagi,  but  electrical  stimulation  of  this  nerve  produces 
only  slight  contractions. — Tk.] 


VOMITING.  377 

tartar  emetic  into  the  blood.  But  Tantini  sliowed  that  tliis  experi- 
ment was  no  longer  successful  after  the  cardia  was  left  attached  to 
the  oesophagus.  Therefore,  during  vomiting  there  must  be  an  active 
opening  of  the  cardia  in  the  manner  already  described.  At  the 
same  time  that  the  cardia  is  opened  the  pylorus  is  tightly  closed, 
and  250werful  peristaltic  and  antiperistaltic  waves,  especially  the 
latter,  traverse  the  organ ;  the  diaphragm  descends  and  becomes  less 
arched ;  the  abdominal  muscles  exert  pressure  on  the  stomach  partly 
directly,  partly  indirectly,  by  compressing  all  the  abdominal  viscera. 
The  larynx  descends,  the  base  of  the  tongue  is  depressed,  and  the 
upper  j^art  of  the  body  is  bent  forward.  All  these  movements  are 
intended  to  facilitate  the  evacuation  of  the  contents  of  the  stomach. 
Indeed,  the  abdominal  pressure  may  be  said  to  exert  most  of  the 
force  necessary  for  the  act.  This  is  well  shown  in  the  easy  vomit- 
ing of  children;  here  we  may  see  the  entire  contents  of  the  stomach 
ejected  from  the  mouth  in  a  large,  continuous  stream,  such  as  could 
never  be  caused  by  peristaltic  contractions.  It  should  also  be  ob- 
served that  the  ability  to  vomit  lessens  with  years,  especially  as  fat 
develops  in  the  abdominal  muscles,  so  that  even  in  one's  student 
days  vomiting  may  only  be  accomplished  by  artificial  pressure  on 
the  abdomen,  even  though  marked  nausea  be  present. 

Of  the  nerves  participating  in  the  act  of  emesis  we  are  here  only 
interested  in  those  distributed  to  the  stomach.  Mechanical  and 
electrical  stimulation  of  the  gastric  mucosa  easily  excites  vomiting, 
since  it  seems  that  it  is  transmitted  along  the  sympathetic  to  the 
vomiting  center  in  the  medulla.  This  has  not  3'et  been  demon- 
strated with  the  other  sensory  stimuli,  and  it  seems  that  most  of  the 
emetics  can  only  act  on  this  center  after  they  have  passed  into  the 
blood.  The  centrifugal  impulses  which  reach  the  stomach  during 
vomiting  proceed  along  the  vagi,  and  effect  the  proper  co-ordination 
of  the  movements  of  the  stomach  with  the  other  muscular  contrac- 
tions essential  to  this  act.  After  section  of  the  vagi  this  co-ordi- 
nation is  lost,  and,  although  vomiting  is  not  impossible,  yet  it  is 
rendered  very  difficult.  It  will  then  only  occur  when  by  chance  the 
increase  in  the  abdominal  pressure  and  the  opening  of  the  cardia 
happen  to  be  simultaneous. 

Sensibility  of  tlie  Stomach. — The  stomach  is  unquestionably  sensi- 


3Y8  DISEASES  OP  THE  STOMACH. 

tive  both  upon  the  mucosa  as  well  as  on  the  serosa.  A  hard  CBSoph- 
aeeal  bougie  is  felt  the  moment  it  touches  the  walls  of  the  stom- 
ach.  So,  also,  in  making  a  gastric  fistula  the  patient  feels  the  ther- 
mo-cautery  as  it  touches  the  stomach  from  without.  The  sensitive- 
ness is  very  limited,  and  strong  stimuli  are  required  to  produce  these 
effects.  ISTormally  we  do  not  feel  our  stomachs  ;  we  neither  feel  the 
weight  of  the  ingesta  nor  do  we  know  where  the  food  lies,  its  tem- 
perature, or  chemical  properties,  whether  acid,  alkaline,  or  bitter ; 
neither  do  we  feel  the  peristalsis  called  forth  by  eating.  But  the 
powerful  stimuli  above  mentioned  prove  that  even  the  healthy  stom- 
ach is  not  utterly  devoid  of  sensation ;  and  as  all  sensory  nerves 
respond  to  the  four  different  kinds  of  stimuli,  viz.,  mechanical, 
electrical,  thermal,  and  chemical ;  these  may  also  be  at  once  assumed 
of  the  sensory  nerves  of  the  stomach.  The  efficiency  of  the  elec- 
trical and  chemical  stimuli  has  also  been  demonstrated ;  this,  com- 
bined with  the  perception  of  the  bougie  and  the  therm o-cautery 
mentioned  above,  demonstrates  that,  to  a  certain  extent  at  least,  all 
of  these  kinds  of  stimuli  are  effective.  The  thinness  of  the  walls  of 
the  stomach  may  at  times  render  it  difficult  to  decide  whether  the 
perception  has  been  on  its  inner  or  outer  surface  ;  it  has  indeed  been 
suggested  that  in  some  cases,  as,  for  example,  the  temperature  of  the 
food,  the  sensations  are  not  in  the  stomach  but  in  the  abdominal 
parietes.  Even  if  this  be  true  under  certain  conditions,  the  fact 
nevertheless  remains  that  the  various  stimuli  mentioned  may  all  be 
perceived  in  the  mucous  membrane  of  the  stomach. 

Pathologically  the  sensitiveness  may  be  increased  even  where 
the  nerves  are  not  exposed,  as  happens  in  gastric  ulcer,  cancer,  etc. 
Under  such  circumstances  irritating  ingesta  which  have  been  swal- 
lowed may  cause  pain,  and  even  touching  the  wall  of  the  stomach 
with  the  bougie  may  produce  unpleasant  sensations. 

To  anticipate  what  will  be  discussed  later  on,  I  will  add  that, 
although  we  do  not  normally  feel  whether  the  stomach  is  empty  or 
not,  yet  we  do  know  when  it  is  overfilled ;  this  may  be  due  to  dis- 
tention and  traction  on  the  gastric  walls. 

All  these  sensations  affect  consciousness  by  means  of  the  pneu- 
mogastric  nerves,  since  the  complete  division  of  these  nerves  will 
prevent  every  conscious  perception  of  the  stomach. 


HUNGER.  379 

Hunger. — The  consideration  of  tlie  causes  and  localization  of  the 
sensation  of  hunger  is  best  taken  up  after  the  above  discussion  of 
the  sensibility  of  the  stomach.  Formerly  the  stomach  was  uni- 
versally regarded  as  the  cause  of  hunger.  Thus,  Haller  thought  it 
was  due  to  the  rubbing  together  of  the  walls  of  the  empty  stomach. 
But  hunger  is  unquestionaljly  a  general  sensation.  It  is  due  to  the 
impoverishment  of  the  blood,  and  has  been  well  called  the  appeal  of 
the  impoverished  metabolism  to  the  brain.  Such  being  its  cause,  it 
can  only  be  definitely  satisfied  by  supplying  the  blood  with  fresh  nu- 
triment. It  has  been  demonstrated  in  animals  that  hunger  is  abol- 
ished by  injecting  nutritious  substances  into  the  blood.  Naturally, 
the  experiment  with  the  corresponding  general  sensation  of  thirst  is 
much  more  easily  carried  out,  since  the  simple  injection  of  water 
easily  relieves  it. 

Recently  there  has  been  no  lack  of  contradictory  statements, 
only  the  more  important  of  which  I  will  now  mention.  Thus,  it  has 
been  said  that  hunger  is  due  to  the  emptiness  of  the  stomach.  But 
rabbits,  guinea-pigs,  and  other  herbivorse,  never  have  emj)ty  stom- 
achs ;  indeed,  the  organ  retains  the  same  degree  of  fullness  which  it 
had  after  the  last  meal,  till  the  fresh  food  which  has  been  taken 
pushes  part  of  the  contents  on  through  the  pylorus.  Here  we  can 
not  speak  even  of  a  relative  emptiness  of  the  stomach  which  might 
cause  the  sensation.  In  carnivora  the  viscus  is  empty  hours  before 
hunger  is  felt,  and  in  new-born  infants  hunger  is  only  manifested 
some  time  after  tying  the  cord,  while  normally  the  stomach  is  empty 
up  to  this  time  without  giving  rise  to  this  feeling. 

Furthermore,  it  has  been  attempted  to  make  not  alone  the  emp- 
tiness of  the  stomach  a  direct  cause,  but  also  the  simultaneous  in- 
creased peristalsis  or  the  lessening  of  the  secretion  of  the  gastric 
juice,  or  even  its  accumulation  in  the  gastric  glands.  But  direct  ob- 
servation shows  that  all  these  suppositions  are  not  tenable,  and 
therefore  can  not  be  advanced  in  explanation  of  this  feeling.  On 
the  other  hand,  section  of  the  vagi  affords  important  proof  that 
hunger  is  a  universal  sensation,  since  it  may  be  felt  even  after  all 
the  fibers  of  these  nerves  have  been  divided.  But,  as  I  have  already 
mentioned,  after  this  has  been  done  no  more  perceptions  can  pro- 
ceed from  the  stomach  to  consciousness. 


380  DISEASES  OP  THE  STOMACH. 

The  vagi  having  been  divided,  reflexes  might  be  transmitted  to 
the  brain  by  the  sympathetic.  Such  a  function  is  generally  not  ac- 
cepted ;  hence  it  has  been  suggested  whether,  after  the  suppression 
of  perceptible  stimuli  from  the  stomach  by  division  of  the  vagi, 
other  kinds  of  excitation  of  the  organ  which  are  not  perceived  as 
such  by  consciousness,  may  not  affect  the  higher  centers,  and  thus 
cause  the  sensation  of  hunger.  But  the  latter  may  be  felt  even  after 
the  simultaneous  division  of  both  the  vagi  and  sympathetic.  There- 
fore the  hunger-center  requires  no  connection  with  the  stomach. 

Where  shall  we  search  for  the  center  ?  At  all  events,  not  in  the 
cerebrum  or  cerebellum,  for  monsters  born  without  these  organs 
give  undoubted  manifestations  of  hunger.  Until  recently  it  was 
observed  that  pigeons  in  which  the  cerebrum  had  been  extirpated 
never  voluntarily  took  food  ;  and  as  they  made  no  movements  which 
could  indicate  hunger,  even  starving  to  death  while  quietly  resting 
on  a  heap  of  peas,  it  was  naturally  supposed  that  with  the  destruc- 
tion of  the  cerebrum  the  sensation  of  hunger  had  also  been  lost. 
But  in  all  experiments  on  the  central  nervous  system  very  great  care 
must  be  exercised  and  inferences  must  be  very  cautiously  drawn. 
Nearly  one  year  after  the  destruction  of  the  cerebrum  in  the  usual 
manner  I  saw  a  pigeon  again  begin  to  take  solid  and  liquid  food 
voluntarily.  This  seems  to  have  been  the  first  case  of  this  kind 
observed.  It  has  also  been  verified  by  Schrader,  but  he  asserts  that 
pigeons  can  only  again  learn  to  eat  when  remnants  of  the  frontal 
lobes  have  been  left  intact.  On  the  other  hand,  the  same  writer 
saw  frogs  catch  and  devour  flies  after  com23lete  removal  of  the 
cerebrum.  Therefore,  this  center  does  not  exist  in  the  cerebrum, 
and  it  has  properly  been  located  in  the  medulla  ;  the  supposition  is 
that  it  is  here  stimulated  directly  without  the  intervention  of  pe- 
ripheral nerves  by  the  blood  circulating  about  it,  whenever  the  per- 
centage of  nutritious  material  in  the  blood  has  been  sufficiently 
lowered  by  giving  it  up  to  the  tissues. 

But  how  can  Ave  reconcile  this  with  the  fact  that  most  people 
locate  the  sensation  of  hunger  in  a  particular  spot  ?  A  comparison 
with  another  general  sensation  which  is  universally  recognized  as 
such — i.  e.,  sleep — teaches  us  how  easily  such  general  sensations  may 
be  combined  with  local  perceptions.    When  we  are  tired  the  feeling 


HUNGER.  381 

of  general  languor  and  tlie  desire  to  sleep  is  accompanied  by  a  heavi- 
ness of  the  eyelids  which  is  often  supplemented  by  itching  or  burn- 
ing. Here  we  distinctly  feel  that  the  general  fatigue  is  associated 
with  a  localized  feeling  in  the  eyelids.  But  in  hunger  the  gen- 
eral sensation  is  so  indefinite  that  it  is  usually  mistaken  for  the 
simultaneous  local  feeling.  Hence,  hunger  is  more  or  less  posi- 
tively located  by  most  persons  in  a  definite  part  of  the  body.  Very 
interesting  in  this  connection  is  the  statement  of  Schiff,  who  asked 
a  large  number  of  soldiers  where  they  experienced  the  sensation 
of  hunger.  Several  located  it  in  the  chest  and  neck,  twenty-three 
over  the  sternum,  four  did  not  know  where  to  place  it,  and  only 
two  mentioned  the  stomach.  Marked  individual  differences  un- 
doubtedly exist  in  the  localization  as  well  as  the  intensity  of  this 
sensation.  After  a  long  fast  many  only  experience  a  moderate,  vague 
feeling  of  oppression,  while  others  regularly  have  an  intense,  almost 
painful  sensation  before  the  usual  meal-hour.  Yet  in  the  majority  of 
persons  who  can  observe  themselves  somewhat  closely  hunger  seems 
to  begin  merely  with  a  vague  oppression  in  the  epigastrium.  This 
localized  sensation  accompanying  the  general  feeling  is  really  cen- 
tral— i.  e.,  it  results  from  the  stimulation  of  the  centers  themselves 
without  any  demonstrable  intervention  of  the  peripheral  nerves. 
The  central  irritation  is  then  transferred  peripherally — that  is,  the 
cause  of  our  perception  is  falsely  referred  to  the  periphery.  Such, 
or  analogous  "  eccentric  transfers "  are  of  frequent  occurrence ; 
thus,  if  the  ulnar  nerve  is  injured,  the  pain  is  felt  in  the  little  finger. 
However,  in  this  example  the  irritant  does  not  act  upon  the  center, 
as  in  the  sensation  of  hunger,  but  only  upon  the  nerve  at  a  place 
which  is  more  centrally  situated  than  the  site  to  which  the  sensation 
is  referred. 

Against  this  interpretation  of  the  localized  feeling  of  hunger  as 
a  central  perception  it  might  be  said  that  the  local  irritation  of  the 
stomach  is  often  followed  by  very  positive  manifestations  of  hunger. 
Thus,  the  first  eft'ect  of  a  growing  cancer  of  the  stomach  may  be  a 
ravenous  appetite.  But  why  may  not  an  "  eccentric  sensation  "  be 
simulated  by  one  which  is  peripheral  'I  Touching  the  spokes  of  a 
rapidly  revolving  wheel  at  times  causes  a  sensation  like  that  of  the 
"  falling  asleep  "  of  a  finger.     On  the  other  hand,  if  this  feeling  of 


382  DISEASES  OP  THE  STOMACH. 

hunger  suddenly  passes  away,  as  through  disgust,  it  is  highly  im- 
probable that  the  perception  of  the  existing  local  irritation  should 
have  been  suj)pressed,  as  such  an  inhibition  usually  results  only 
from  the  most  intense  psychical  excitement.  In  the  heat  of  a  battle 
the  pain  of  a  wound  may  not  be  felt  even  if  the  attention  has  been 
casually  directed  to  it ;  here  stimuli  are  acting  w^hich  affect  the  mind 
to  the  highest  degree.  But  if  these  stimuli  be  feeble,  as,  for  exam- 
ple, the  recei|)t  of  some  unexpected,  affecting  news,  be  it  good  or 
bad,  we  can  nevertheless  always  positively  say  whether  there  is  any 
abnormal  sensation  in  any  part  of  the  body ;  our  judgment  will  in 
no  wise  be  different  than  usual.  At  all  events,  in  such  a  case  we 
can  remove  this  inhibition  which  may  finally  have  resulted  from 
the  mental  excitement  by  directing  the  attention  to  the  part  of  the 
body  in  question.  But  if  through  mental  excitement  we  have  lost 
our  desire  for  food — I  will  rather  say  the  sensation  of  hunger — we 
may  sit  down  at  the  table,  we  may  long  to  eat,  we  may  concentrate 
our  entire  attention  upon  the  appetite,  yet  this  feeling  of  hunger 
remains  away.  What  trifling  excitements  sometimes  cause  this  in 
many  persons  —  the  news  that  a  good  friend  is  coming,  the  falling 
of  a  fly  in  the  soup,  or  the  narration  of  disgusting  stories  !  How 
remarkable !  A  person  may  attempt  to  spoil  another's  appetite  by 
telling  such  stories  ;  and  he  may  succeed,  in  spite  of  the  most  strenu- 
ous efforts  of  the  eater  not  to  be  influenced  by  these  recitals.  It 
will  always  be  futile  to  use  such  feeble  mental  efforts  to  suppress 
sensations  due  to  peripheral  irritants,  even  if  they  be  slight  or  pro- 
ceed from  without  or  M'ithin  the  body.  The  abnormal  sensation 
will  always  return  whenever  the  attention  is  directed  to  one's  own 
body. 

It  is  different  with  sensations  of  central  origin.  Continuous  self- 
observation  will  at  times  show  that  a  headache  may  entirely  disap- 
pear as  a  result  of  moderate  mental  excitement ;  possibly  even  more 
convincing  is  the  feeling  of  fatigue  which  so  often  leaves  us  after 
slight  mental  exertion  and  then  is  craved  back  again  in  vain.  I 
therefore  believe  that  hunger  is  of  purely  central  origin,  and  that  it 
is  only  indirectly  connected  with  the  "rumblings  of  an  emjDty 
stomach." 

Just  as  we  can  drive  away  sleep  for  a  short  time  by  abolishing 


HUNGER.  383 

the  sensations  by  wliicli  it  manifests  itself  loeallj,  so  can  we  do  tlie 
same  with  Imnger.  AVasliing  the  eyes  with  cold  water  will  keep  one 
awake.  Hunger  may  be  put  off  by  introducing  indigestible  sub- 
stances into  the  stomach  or  by  comjjressing  this  viscus  with  a  tight 
belt,  as  is  frequently  done  by  the  common  people.  But  both  of 
these  general  sensations  have  only  been  treated  symptomatically, 
and  have  not  really  been  suppressed.  It  is  merely  using  the  familiar 
method  of  obscuring  one  sensation  by  a  stronger  one  at  the  site  of 
the  former,  or  where  this  may  be  referred  in  the  periphery. 

Even  if  we  thus  succeed  in  removing  the  manifestations  of  hun- 
ger which  appeal  most  powerfully  to  consciousness,  true  hunger  can 
nevertheless  be  satisfied  only  by  introducing  nutritious  material  into 
the  circulation.  But  it  is  a  well-known  fact  that  when  we  are 
very  hungry  and  have  waited  too  long  after  the  usual  time  of  eat- 
ing— so  that  the  stomach  "  rumbles,"  we  yawn  and  feel  w^eak,  etc. — 
a  few  bites  will  satisfy  us  and  relieve  these  distressing  symptoms. 
But  is  it  possible  that  in  so  short  a  time  sufficient  food  has  been 
absorbed  to  satisfy  this  want  ?  By  no  means.  Only  the  more  urgent 
manifestations  have  been  assuaged,  exactly  as  happens  after  swal- 
lowing indigestible  substances  and  tightening  a  belt.  Eating  a  meal 
first  satisfies  the  urgent  signs  of  hunger,  but  we  are  not  really 
satiated  then  ;  the  true  hunger  is  appeased  very  slowly  during  the 
meal  and  the  period  of  digestion.  The  true  sign  of  being  sated  is 
that  condition  of  the  blood  which  no  longer  stimulates  the  hunger- 
center  ;  hence  the  latter  ceases  to  send  out  impulses  to  the  other 
centers  w^hich  cause  this  feeling  to  be  manifested. 

According  to  this  theory,  that  satiation  denotes  a  state  of  quies- 
cence of  the  hunger-center,  the  feeling  is  of  a  negative  character. 
Hence  it  might  be  objected  that  it  would  then  be  impossible  to  be 
es]3ecially  "  full "  after  a  large  meal,  I  might  almost  say  over-satiated. 
But  in  order  to  show  that  this  is  really  an  objection  to  the  theory 
it  must  first  be  demonstrated  that  the  sensation  is  due  to  an  excess 
of  nutrition  in  the  blood  above  what  is  needed  for  satiation.  This 
is  evidently  not  the  case.  TVe  can  not  feel  whether  more  nourish- 
ment than  is  necessary  is  circulating  in  the  blood,  just  as  we  are  un- 
able to  tell  whether  the  sleep  from  wdiich  we  have  just  awakened 
will  suffice  for  a  longer  or  shorter  time.     Consequently,  after  having 


g34  DISEASES   OF   THE  STOMACH. 

satisfied  ourselves  at  a  meal,  and  provided  we  Lave  no  other  guide 
than  our  sensations,  we  will  not  know  whether  we  will  feel  hungry 
sooner  or  later.  The  real  cause  of  the  varying  degrees  of  satiation 
after  a  meal  is  simply  the  distention  of  the  stomach,  for  which,  as 
already  stated  (p.  378),  we  have  a  distinct  perception.  "Whether  the 
stomach  feels  especially  full  or  not  depends  on  the  usual  size  of  the 
meals.  If  we  give  only  meat  and  wheat  bread  to  an  Irish  peasant, 
who  is  accustomed  to  distend  his  stomach  Avith  potatoes,  he  will  feel 
sated  after  having  taken  a  much  larger  amount  of  nutriment  than 
usual ;  in  spite  of  this,  he  will  not  feel  that  he  has  eaten  too  much, 
unless  his  stomach  is  unusually  distended.  On  the  other  hand,  if 
w^e  give  innutritions  and  bulky  food  to  a  ^^erson  whose  chief  article 
of  diet  has  been  meat,  he  will  feel  over-sated  when  his  stomach  is 
uncommonly  distended,  even  if  he  has  taken  less  nourishment  than 
usual.  Hence  tlie  feeling  of  over-satiation  is  really  not  due  to  such 
a  condition,  but  is  to  be  regarded  only  as  a  new  and  positive  sensa- 
tion, resulting  from  an  unusual  distention  of  the  stomach,  and 
which  to  some  extent  may  be  regarded  as  a  warning  against  over- 
loading this  organ. 

Finally,  I  must  discuss  the  appetite.  Let  us  again  use  the  simile 
between  hunger  and  general  fatigue.  If  we  are  tired  and  wish  to 
sleep,  it  is  essential  that  certain  parts  of  the  brain  should  not  be  ex- 
cited. The  absence  of  such  excitement  puts  us  into  the  condition 
of  sleepiness.  ISTot  alone  do  we  wish  to  sleep,  not  alone  do  we  feel 
the  need  of  repose,  but  we  also  experience  the  sensation  that  we  will 
soon  be  asleep  if  we  simply  keep  quiet.  The  same  exertions  which 
have  at  first  tired  us  may  excite  us  if  they  are  kept  up  too  long. 
Then  we  are  overtired.  In  the  same  way  certain  mental  exertions 
may  be  exciting ;  in  both  cases,  in  spite  of  the  fact  that  we  feel  a 
very  well  marked  need  of  rest,  we  are  yet  unable  to  sleep — that  is, 
we  are  not  drowsy. 

Aj)petite  bears  the  same  relation  to  hunger  that  drowsiness  does 
to  sleep.  JSTornially,  both  sensations,  hunger  and  appetite,  precede 
the  taking  of  food ;  but  we  may  be  over-hungry  as  we  may  be  over- 
tired. Of  the  mental  excitements  which  may  suppress  hunger  I 
have  already  spoken.  Sensory  stimuli  act  in  this  same  way  upon 
drowsiness  and  appetite ;  a  cold  sponging  may  awaken  us,  and  an 


HUNGER.  385 

ofEensive  taste  or  smell  may  spoil  our  appetites.  Finally,  however, 
sleep  as  well  as  luiTiger  overcome  all  obstacles  and  imperatively  de- 
mand their  rights. 

We  must  therefore  assume  that  the  true  hunger-center,  which  is 
influenced  by  the  impoverished  condition  of  the  blood,  sets  into  ac- 
tion a  large  series  of  secondary  centers,  which  in  their  turn  produce 
the  manifest  signs  of  hunger ;  and  upon  their  activity  depends  the 
occurrence  of  appetite.  If  we  have  no  appetite,  as,  for  example, 
when  we  are  over-hungry,  then  these  centers  are  inhibited  ;  the  most 
pressing  and  distinct  signs  of  hunger  which  urge  us  to  eat  are  absent, 
and  only  a  vague  general  feeling  tells  us  that  we  are  nevertheless 
not  sated.  However,  the  nature  of  appetite  consists  not  alone  in  a 
demand  for  taking  food,  and  a  preference  for  certain  articles  of  diet 
(if  this  were  the  case,  then  there  would  be  an  analogous  sensation 
in  the  condition  of  thirst,  which,  however,  does  not  exist,  and  for 
which  also  there  is  no  word  in  the  language) ;  but  the  appetite  may 
also  exclude  certain  articles  of  diet  which  are  relished  at  another 
time.  The  latter  lends  a  special  characteristic  to  this  feeling.  Of 
the  many  instances  which  might  be  quoted  to  illustrate  this  I  will 
simply  recall  the  striking  repugnance  toward  fats  in  jaundice.  The 
simple  sight  of  butter  may  excite  disgust  even  in  persons  who  have 
been  fond  of  butter  or  fatty  food.  I  do  not  know  any  analogous 
instances  of  this  regarding  thirst — that  is,  in  so  far  as  the  fluids  are 
simply  to  allay  thirst,  but  are  not  to  have  any  great  nutritive  value, 
as  milk,  chocolate,  etc.  Here  it  is  only  over-indulgence  which 
causes  a  diso-ust  toward  favorite  beverasfes. 

The  taking  of  food  brings  into  action  a  very  large  number  of 
special  centers.  Among  these  are  the  centers  for  taste  and  smell, 
the  secretion  of  saliva,  the  voluntary  and  involuntary  acts  of  deglu- 
tition, etc.  "We  also  have  a  very  distinct  feeling  whether  a  certain 
article  will  influence  the  taking  of  food  favorably  or  unfav^orably. 
Even  the  thought  of  them  will  act  in  the  same  M'ay  as  the  dishes 
themselves,  but,  of  course,  to  a  feebler  degree.  If  we  notice  that 
the  smell  or  taste  of  a  dish  is  unpleasant,  that  the  secretion  of  saliva 
is  lessened,  and  that  deglutition  is  inhibited  (a  sensation  which  is 
characterized  in  its  most  marked  form  as  a  "  ziigeschnurte  Kehle  "), 
then  this  article  of  food  becomes  repugnant  to  us.     Such  an  occur- 


386  DISEASES  OF  THE  STOMACH. 

rence  will  explain  why  this  peculiarity  does  not  occur  in  the  analo- 
gous sensation  of  thirst,  or,  if  present,  is  very  feebly  marked  ;  that 
is,  the  act  of  drinking  does  not  call  these  centers  of  salivary  secre- 
tion, deglutition,  etc.,  into  play  to  the  same  degree.  Naturally, 
a  favorable  influence  on  the  above  centers  will  cause  a  longing  for 
special  foods. 

In  my  opinion,  appetite  is  due :  (1)  to  the  excitation  of  those 
centers  which  cause  the  manifest  symptoms  of  hunger,  and  th^  ac- 
tion of  which  is  regulated  by  the  true  hunger-center ;  (2)  to  the 
favorable  or  unfavorable,  stimulating  or  inhibitory  action  of  the 
secondary  centers  concerned  with  the  taking  of  food. 


LECTUEE   X. 

THE   NEUEOSES    OF   THE    STOMACH. — {Conti7lU€d.) 

Classification. — The  neuroses  of  tlie  stomach  may  arise  either 
directly  from  diseases  of  this  visciis,  or  they  may  be  caused  reflexly 
from  other  organs — the  brain,  spinal  cord,  uterus,  kidneys,  liver, 
etc. ;  thus  the  gastric  nervous  centers  may  be  called  into  action, 
either  directly  or  reflexly.  Yet,  in  the  majority  of  cases,  as  Oser 
has  shown,  a  sharp  distinction  can  not  be  made ;  as  an  example  he 
cites  the  so-called  reflex  cardialgias  in  uterine  disorders  where  both 
affections,  the  uterine  and  the  gastric,  might  be  considered  concur- 
rent, as  well  as  standing  in  a  causal  relation  to  each  other. 

In  the  following  table  of  the  various  neuroses  I  have  followed  a 
classification  which  is  midway  between  the  purely  symptomatic  and 
the  etiological,  in  order  that  a  better  general  idea  may  thus  be  ob- 
tained. 

THE  NEUROSES   OF   THE   STOMACH. 
I.  Conditions  of  Irritation. 

a.  Sensory.  b.  Secretory.  c.  Motor. 

Hyperesthesia.  Hyperacidity.  Eructation. 

Nausea.  Hypersecretion.  Pyrosis. 

Hyperorexia.  Vomiting. 

Anorexia  ex  hyperassthesia.  Colic. 

Parorexia.  Tormina  yentriculi. 

Gastralgia. 

II.  Conditions  of  Depression. 

Anaesthesia.  Anacidity.  Atony. 

Polyphagia.  Insufficiency  of  the 

pylorus  and  cardia. 
II  r.  Mixed  Form. 

Gastro-intestinal  neurasthenia  (Dyspepsia  nervosa). 

IV.  Reflexes  from  other  Organs  upon  the  Gastric  Nerves. 

Reflexes  from  the  brain,  spinal  cord,  kidneys,  liver,  sexual  organs,  and  intes- 
tines manifest  themselves  in  the  forms  mentioned  in  I  and  II.* 

-    *  I  wish  to  state  that  some  time  after  the  appearance  of  the  first  edition  of  this 
25  (387) 


388  DISEASES   OF    THE   STOMACH. 

Occurrence  and  Etiology. — In  looking  over  the  various  neuroses 
enumerated  in  the  above  table  we  should  never  forget  that  thej 
rarely  occur  as  distinct,  independent  diseases,  but  usually  in  groups, 
either  appearing  simultaneously  or  closely  following  one  another 
during  the  course  of  the  malady,  passing  before  us  like  a  panorama 
with  ever-changing  scenes.  To  prevent  needless  repetitions  let  it  be 
said,  once  for  all,  that  these  conditions  occur  'most  freqxiently  in 
woynen,  and  especially  the  younger  rather  than  those  further  ad- 
vanced in  years.  It  is  hardly  necessary  for  me  to  say  that  this  is 
due  to  the  greater  predisposition  of  women  to  the  functional  neu- 
roses, and  to  their  great  frequency  before  the  climacteric  rather  than 
after  it.  In  both  sexes  the  middle  period  of  life,  from  about  the 
twentieth  year  onward,  is  most  frequently  the  time  of  their  occur- 
rence ;  they  are  less  common  before  this  time,  and  least  of  all  after 
the  fifties. 

ISTo  such  general  rules  like  those  for  sex  and  age  can  be  formu- 
lated for  the  condition  of  these  patients.  Some  of  them  have  severe 
disturbances  of  nutrition,  are  feeble,  emaciated,  anaemic  persons  with 
a  faded,  pale  complexion,  through  which  the  veins  may  be  seen ;  they 
have  languid  eyes,  a  weak  voice,  feeble  movements,  and  a  dragging 
gait ;  some  are  even  bedridden ;  while,  on  the  other  hand,  we  are 
astonished  to  see  people  enter  our  offices  who  are  apparently  healthy 
and  vigorous,  and  with  red  cheeks,  yet  who  com23lain  of  a  host  of 
nervous  disturbances.  There  are  also  exceptions  to  the  well-known 
rule  that  the  people  attacked  with  the  gastric  neuroses  are  usually 
those  who  live  in  large  cities,  and  especially  those  better  situated, 
whose  struggle  for  existence  demands  an  especial  expenditure  of 
labor  and  mental  excitement  to  keep  up  with  the  demands  of  an 
"  advanced  culture."  I  have  seen  quite  severe  neuroses  in  persons 
of  the  lower  classes — farmers,  working  people,  female  servants,  fac- 
tory-girls, and  finally,  where  one  would  least  expect  it,  in  sailors. 

K^ predisposing  factors  \X  is  not  difficult  to  recognize  the  rela- 
tions of  severe  mental  exertions  of  men  in  their  business  affairs,  and 
in  women  the  absolute  or  relative  excess  of  social  duties  and  pleas- 
book  a  table  which  is  very  similar  to  the  above  was  published  by  Garland  in  a 
paper  on  Gastric  Neurasthenia,  Boston  Medical  and  Surgical  Journal,  October  3, 
1889. 


OCCURRENCE   OP   GASTRIC  NEUROSES.  389 

m-es ;  and  in  both  sexes  tlie  excessive  use  of  the  sexual  organs. 
For,  not  infrequently,  we  see  cases  of  periodically  recurring  neu- 
roses which  are  due  to  periodical  increase  of  these  causes,  inasmuch 
as  the  amount  of  work  and  of  pleasures  is  greater  at  some  times  and 
is  less  at  others ;  this  increase  and  diminution  are  accompanied  Ly 
a  corresponding  increase  or  lessening  or  even  disappearance  of  the 
nervous  sj^mptoms.  Stiller  observed  an  exacerbation  of  the  neuroses 
in  some  of  his  patients  in  the  spring ;  in  my  practice  the  majority  of 
these  patients  come  at  the  close  of  the  winter.  Yet,  as  the  patients 
usually  allow  some  time  to  elapse  before  consulting  a  physician,  this 
would  afford  very  little  information  as  to  the  origin  of  these  disor- 
ders ;  but  the  patients  themselves  frequently  assert  that  in  the  quiet 
season  they  feel  entirely  or  relatively  well. 

Almost  without  exception  these  patients  have  sjmiptoms  of  gen- 
eral neuroses  as  well  as  their  gastric  complaints ;  naturally  these  are 
often  not  well  marked,  or  are  not  considered  by  the  patient  to  be- 
long to  the  actual  trouble,  so  that  a  thorough  examination  may  be 
needed  to  bring  them  to  light.  We  may  then  discover  a  so-called 
nervous  temperament,  headaches  of  various  location  and  character, 
disinclination  toward  mental  exertion,  depression,  mental  sluggish- 
ness, poor  memory,  absence  of  mind,  vertigo  and  its  curious  mani- 
festation agoraphobia,  insomnia,  neuralgias  and  parasthesi^,  espe- 
cially of  the  trigeminus  and  in  the  lower  extremities,  pupillary  dif- 
ferences, evidences  of  spinal  irritation,  intercostal  neuralgias,  vesical 
weakness,  and  ovarian  pains — all  of  these  manifestations  relegating 
such  patients  to  the  great  class  of  neurasthenics.  If  the  disturbances 
of  the  diseased  mind  are  projected  along  the  most  varied  nervous 
tracts— i.  e.,  forming  the  capricious  and  confusing  picture  of  hys- 
teria— another  and  almost  equally  frequent  class  of  cases  will  be 
grouped.  IsTaturally,  it  is  impossible  in  every  case  to  draw  a  sharp 
line  between  neurasthenia  and  hysteria.  The  marked  cases  of  each 
are  easily  recognized,  but  there  is  a  border  province  in  which  the 
judgment,  I  would  like  to  say  the  tact,  of  the  physician  must  decide 
the  diagnosis.  For  our  present  purposes  it  is  sufficient  to  know 
that  the  neuroses  of  the  stomach  are  usually  (although  not  always) 
only  a  partial  manifestation  of  general  nervousness  in  the  broadest 
sense  of  the  word — i.  e.,  of  neurasthenia  and  hvsteria  :  the  verv  im- 


390  DISEASES  OP  THE  STOMACH. 

portant  deduction  from  this  fact  is  that  tlie  main  object  of  the  treat- 
ment is  to  cure  the  primary  affection,  and  is  not  to  he  directed  only 
to  a  single  symptom,  however  prominent.  This  will  impart  an 
almost  uniform  character  to  the  therapeutic  measures  for  these 
troubles,  and  hence  the  essential  features  of  the  treatment  will  al- 
ways be  the  group  of  nervines,  including  both  medical  and  dietetic 
measures.  I  shall  therefore  consider  the  treatment  of  the  gastric 
neuroses  collectively  at  the  close  of  this  subject. 

I.  Conditions  or  Ikeitation". 

Proceeding  from  these  general  considerations  to  the  special,  I 
will  first  mention  the  mildest  disturbances  of  sensation,  hyperaesthesia 
of  the  stomach,  which  manifests  itself  in  a  feeling  of  fullness  and 
tension  as  well  as  oppression  in  this  region,  and  nausea.  These  sen- 
sations are  so  closely  allied  to  the  normal,  and  are  the  daily  and  con- 
stant accompaniments  of  so  many  digestive  disturbances,  that  they 
include  the  entire  series  of  gastric  disorders,  from  the  "  full  stom- 
ach" after  a  good  dinner  and  the  symptoms  of  intoxication  after  a 
strong  cigar,  up  to  the  incessant  oppression  and  fullness  in  the  epi- 
gastrium felt  by  many  patients  with  cancer,  the  burning  sensation 
in  the  abdomen,  and  nausea  which  may  accompany  liysteria,  menin- 
geal irritation,  cerebral  tumors,  and  other  diseases  of  the  central 
nervous  system.  As  concomitant  manifestations  of  other  diseases 
tliey  must  be  disregarded  here,  for  I  shall  limit  myself  to  the  gen- 
uine neuroses.  But  it  is  difficult  to  define  the  latter  exactly,  to 
recognize  these  symptoms  as  such — in  other  words,  to  group  them  as 
liypersesthesise  of  the  stomach. 

Positive  information  can  only  be  obtained  after  a  careful  and 
thorough  examination  with  all  the  means  for  the  differential  diag- 
nosis of  the  various  organic  gastric  disorders.  Furthermore,  one 
must  not  forget  that  many  patients,  either  through  carelessness  or 
because  they  locate  falsely,  attribute  many  painful  sensations  to  the 
stomach,  which  really  do  not  exist  there,  but  in  the  epigastrium  (the 
so-called  epigastric  j)ain  of  Briquet,  myalgia  of  the  abdominal  mus- 
cles) ;  such  pains  are  usually  the  result  of  cutaneous  hyperaesthesia 
or  muscular  rheumatism,  or  may  even  proceed  from  the  spinal  col- 
umn.    That  the  greater  number  of  patients  observe  themselves  very 


HYPERESTHESIA  OF  STOMACH.  391 

carelessly,  and  are  very  reckless  in  localizing  painful  sensations,  is  a 
daily  experience ;  hence  the  patient  must  not  alone  describe  the 
painful  spot,  but  he  must  also  point  it  out  to  me.  Oser  has  fre- 
quently seen  sufferers  from  locomotor  ataxia  who  referred  the  site 
of  their  troubles  to  the  stomach,  although  they  did  not  suffer  from 
gastric  crises ;  they  had  mistaken  the  girdle  sensation  perceived  in 
the  epigastrium  for  gastric  sensations. 

The  knowledge  of  hypersesthetic  conditions  of  the  mucous 
membrane  of  the  stomach  is  very  old.  Todd*  cites  examples  from 
Hippocrates  and  Aretseus  ;  Schmidtraann  f  and  Barras  :}:  knew  of 
them — the  latter,  strange  to  say,  under  the  name  of  dyspepsia. 
Pemberton  considered  it  a  condition  of  muscular  irritability.  J. 
Johnson  describes  it  as  a  "  morbid  sensibility  of  the  stomach " ; 
while  Todd  cites  cases  under  the  name  of  "  irritable  gastric  dys- 
pepsia." 

The  characteristic  feature  of  hypersesthesia  is  an  increased  irri- 
tability of  the  stomach,  the  result  of  which  is  that  the  gentlest  irri- 
tants, including  even  those  which  are  normal,  may  call  forth  very 
painful  sensations  ;  the  latter  may  sometimes  occur  even  without 
the  presence  of  such  direct  irritants.  And  yet  these  same  sensory 
nerve-endings  in  the  mucous  membrane  of  the  stomach  are  other- 
wise so  tolerant !  When  well,  we  know  nothing  of  the  existence  of 
the  stomach,  and  much  less  of  its  functions  ;  but  in  these  patients 
there  is  a  continuous  sensation  of  heat  or  cold,  gnawing,  pulling, 
burning  in  the  organ,  which  may  exert  such  a  powerful  influence 
on  the  physical  and  mental  life  of  the  patients  that  every  sensation, 
and,  in  fact,  anything  which  attracts  their  attention,  is  considered 
in  its  relations  to  their  stomachs.  "  Le  principe  de  tons  mes  maux 
est  dans  mon  ventre ;  il  est  tellement  sensible,  que  peine,  douleur, 
plaisir,  en  un  mot  toute  espece  d'affections  morales  ont  la  leur  prin- 
cipe. Je  pense  par  le  ventre  si  je  puis  m'exprimer  ainsi."  This  is 
what  a  lady  wrote  to  Pinel ;  it  is  a  splendid  description  of  a  con- 
dition which  has  been   called   hypochondria  ;   at  all  events,  it   is 

*  hoc.  ciU  p.  633. 

f  J.  Schmidtmann.    Summa  observationum  medicarum  ex  praxi  cliniea  triginta 
annorum,     Berolini,  1819-1826. 

%  Barras.     Traits  sur  les  gastralgies  et  enteralgies.     Paris,  1827. 


392  DISEASES   OP   THE  STOMACH. 

located  in.  the  hypochondrium,  but  it  undoubtedly  also  belongs  to 
tlie  hypersesthetic  conditions  of  the  stomach. 

The  nerv^ous  nature  of  these  disturbances  is  also  shown  by  the 
fact  that,  in  some  cases,  taking  food  moderates  them ;  but  they  may 
become  worse  after  the  stomach  has  again  emptied  itself  ;  however, 
in  the  majority  of  cases  the  reverse  is  true,  and  the  trouble  is 
aggravated  during  digestion.  Sometimes  the  sensations  described 
above  appear  only  after  taking,  even  very  small  amounts — as,  for 
example,  a  glass  of  water.  Then  everything  which  has  been  taken 
is  vomited,  and  remedies  which  are  usually  well  borne  now  cause 
severe  pain,  clammy  sweats  due  to  fear,  and  even  convulsions  and 
collapse  ;  mild  aperients  may  be  followed  by  severe  diarrhoea. 

Sometimes  the  hypersesthesia  is  preceded  by  a  tangible  cause. 
Thus,  for  example,  it  occasionally  follows  chloroform  narcosis. 
Such  a  case  I  have  recently  seen : 

A  young  woman,  twenty-eight  years  old,  suffered  from  tabes,  and  also 
had  a  carcinoma  of  the  anterior  lip  of  the  os  uteri ;  the  latter  was  removed 
under  nai'cosis.  Before  the  operation  her  appetite  and  digestion  were 
excellent.  For  three  days  after  she  remained  in  a  condition  in  which 
she  complained  of  severe  burning  in  the  stomach  and  an  unquenchable 
thirst ;  everything  she  ate  was  vomited  after  a  short  time.  Several  times, 
on  the  day  after  the  operation,  I  examined  the  vomit,  which  consisted  of 
weak  coffee,  and  always  found  hydrochloric  acid  in  it.  Small  pieces  of 
ice,  morphine  injections,  and  large  doses  of  morphine  and  cocaine  inter- 
nally were  useless.  The  vomiting,  which  was  never  spontaneous,  ceased 
only  a  few  days  before  death.  Peritonitis,  which  had  been  suspected  to 
be  the  cause  of  the  obstinate  vomiting,  was  not  found  at  the  autopsy. 

In  this  case  there  was  an  acute  irritation,  which  could  only  have 
arisen  from  the  nerves  ;  here  its  origin  was  central.  In  the  chronic 
form,  the  same  may  be  true  of  a  number  of  the  above-mentioned 
disorders,  while  in  others  the  seat  of  the  irritation  is  peripheral. 
Among  the  causes  given  is  insufficient  food  for  a  long  period,  or 
sudden  restriction  of  diet ;  thus,  prolonged  fasting  is  said  to  have 
caused  hypersesthesise  of  the  stomach  in  Catholic  priests,  fakirs,  and 
Brahmans ;  excesses  and  an  enfeebled  bodily  condition  are  said  to 
favor  their  development.  On  the  other  hand,  more  material  causes 
are  also  given,  as,  for  example,  gastric  calculi,"  the  well-known  con- 

*  [Gastric  calculi,  or  gastroliths,  sometimes  reach  a  very  large  size.  A  unique 
case  of  this  kind  was  reported  by  Kooyker  (Zeitschr.  fur  klin.  Med.,  Bd.  xiv,  Heft  3). 


IDIOSYNCRASIES.  393 

cretiones  benzoarticse,*  and  worms.  In  many  cases  the  causal  fac- 
tors will  be  sought  for  in  vain.  Thus,  I  have  now  under  my 
treatment  a  strong  young  man,  in  good  circumstances,  thirty  years 
old,  who  has  developed  this  condition ;  as  yet  I  can  discover  no 
cause  for  it,  with  the  possible  exception  of  a  transient  gastric  ca- 
tarrh. 

Idiosyncrasies  may  also  be  included  among  the  hypersesthesiae. 
As  is  well  known,  the  eating  of  certain  foods  by  predisposed  indi- 
viduals is  followed  by  peculiar  sensations  in  the  epigastrium,  mild 
oppression  or  burning,  and  sometimes  mild  nausea,  combined  with 
singular  excitation  of  the  cutaneous  nerves,  pruritus,  erythema,  and 
the  formation  of  wheals  [urticaria]  ;  even  headache  and  mild  febrile 
movements  which  either  soon  disappear  of  themselves,  or  are  sub- 
dued by  the  strong  reflex  irritants  from  the  gastric  mucous  mem- 
brane, as  strong  wines,  cognac,  and  the  like.  This  condition  most 
frequently  follows  the  eating  of  shell-lish,  crabs,  lobsters,  etc.,  some- 
times also  oysters,  strawberries,  or  green  peas.  Here  we  are  surely 
not  dealing  with  a  psychosis,  but  only  with  an  abnormal  sensitive- 
ness of  the  gastric  nerves  toward  these  articles  of  food.  For  its  first 
occurrence  is  purely  accidental,  and  it  recurs  after  these  conse- 
quences have  long  since  been  forgotten. 


The  patient  was  a  druggist,  thirty-five  years  old,  who  had  a  circumscribed  tumor 
in  the  epigastrium,  the  position  of  which  varied  on  respiration,  and  which  was  ten- 
der on  pressure.  Medicines  had  no  permanent  effect.  Spleen,  liver,  and  kidneys 
normal.  Appetite  good  ;  bowels  regular.  Occasional  vomiting  of  a  small  quantity 
of  fluid  containing  mucus  and  bile,  but  never  free  hydrochloric  acid.  Nausea  was 
constant,  and  it  was  said  hfematemesis  occurred,  but  this  was  not  actually  observed. 
Gradual  emaciation  followed,  with  cachexia  and  indolent  swelling  of  the  left  supra- 
clavicular and  axillary  glands.  The  patient  was  examined  under  an  anaesthetic  and 
the  stomach  washed  out,  but  exploratory  incision  was  steadily  refused.  The  diag- 
nosis, according  to  the  probabilities,  was  cancer  of  the  stomach.  The  case  ended 
fatally ;  the  autopsy  showed  that  the  stomach  was  normal  in  size,  but  contained  a 
large  concretion,  weighing  885  grammes  (over  28  ounces),  and  having  the  outlines 
of  the  organ.  At  the  pyloric  end  there  were  two  smaller  fragments,  the  size  of 
hen's  eggs.  The  gastrolith  had  a  strong  faecal  odor,  but  contained  no  skatol.  No 
nucleus  was  present.  Microscopic  examination  showed  starch  granules,  cells  con- 
taining chlorophyl,  bundles  of  vessels,  but  nothing  to  determine  the  animal  origin 
of  the  concretion.  It  was  identical  in  composition  with  the  "food-balls'"  of  rumi- 
nants.— Abstract  from  Universal  Annual  Medical  Sciences,  1889,  vol.  i. — Tr.] 

*  [These  are  of  very  frequent  occurrence  in  the  abomasum,  or  fourth  stomach 
of  ruminants.  See  Lancet,  1888,  vol.  i,  p.  186.  For  hair-tumors  of  the  stomach, 
vide  supra,  p.  199. — Te.] 


394  DISEASES  OP  THE  STOMACH. 

A  very  peculiar  condition  which,  may  also  be  included  among  the 
idiosyncrasies  was  recently  observed  by  me  in  a  man,  fifty -one  years  old, 
in  whom  "  the  smallest  quantities  of  fat "  caused  sev^ere  migraine,  tempo- 
rary partial  amaurosis  (Flimmerscotom),  flatulence,  and  the  passage  of 
watery  and  very  offensive  stools.  This  condition  was  said  to  occur  twelve 
to  fourteen  hours  after  taking  fatty  food  ;  the  expression  "  fatty  "  is  ob- 
viously very  vague,  and  refers  only  to  the  more  or  less  oily  additions  to 
the  ordinary  articles  of  food.  It  was  characteristic  of  a  neurosis  that  he 
could  eat  pure  table  butter  without  any  inconvenience,  but  as  soon  as  he 
had  tasted  butter  which  had  been  rendered  the  peculiar  attacks  came  on ! 
Otherwise  this  patient,  who  moved  in  the  best  society,  had  a  good  appe- 
tite, was  robust,  and  had  no  real  gastric  disturbances.  In  the  intervals 
between  the  attacks  the  bowels  were  regular.  In  order  to  remove  every 
suspicion  of  an  insufficient  decomposition  or  absorption  of  the  fats,  the 
passages  were  examined  on  three  different  occasions  after  an  attack,  and 
the  amount  of  fat  was  ascertained  by  means  of  extraction  with  ether ;  but 
the  amount  was  always  found  normal  in  comparison  with  the  small 
quantity  of  fat  which  he  consumed.  The  patient  had  sufl'ered  from  this 
trouble  for  years,  was  himself  convinced  that  he  was  ''  very  nervous,"  and 
had  derived  no  benefit  from  living  in  the  mountains  or  at  the  sea-shore, 
nor  from  drinking  the  waters  at  Carlsbad  and  Kissingen,  nor  from  the 
use  of  preparations  of  pancreatin  and  the  like. 

The  deviations  from  the  feeling  of  hunger  constitnte  a  second 
series  of  sensations  which  become  pathological  by  a  gradual  increase 
of  those  which  were  originally  normal.  As  is  well  known,  the 
length  of  time  during  which  one  can  endure  Imnger,  or,  to  express 
it  more  properly,  during  which  one  need  not  eat  anything,  is  sub- 
ject to  very  extraordinary  variations.  Some  people  are  satisfied 
with  two  meals  a  day,  a  good  breakfast  and  a  substantial  dinner  at 
6  or  7  p.  M. ;  while  others  must  eat  every  three  or  four  hours. 
Unless  this  is  done  they  experience  the  sensation  of  emptiness  of 
the  stomach,  and  faintness,  which  may  even  reach  such  a  degree  in 
nervous  persons  that  they  lose  consciousness ;  the  French  call  this 
defailliance.  I  have  treated  a  state  official  who  was  utterly  unable 
to  take  even  a  glance  at  a  newspaper  unless  he  had  had  Jiis  break- 
fast exactly  at  his  regular  time. 

An  exaggeration  of  this  condition  is  bulimia  (6  Xt/ic9,  hunger, 
o  /3oi)9,  ox  *) ;  it  is  also  called  cynorexia  [o  kv(ov^  dog,  ?;  ope^L<i,  de- 
sire] or  fames  canina ;  hyperorexia,  Ileissliunger  or    Wolfshunger. 


*  This  etymology  is  according  to  Roth-Gessler's  Klinisehe  Terminologie.     Er- 
langen,  1884. 


BULIMIA.  395 

Sometimes  tins  condition  is  only  temporary  and  quite  closely  allied 
to  the  normal  sensations ;  at  other  times  it  is  permanent ;  in  the 
latter  it  constitutes  a  very  obstinate,  weakening,  and  exceedingly 
unpleasant  malady. 

It  may  occur  alone  or  may  be  a  symptom  of  the  various  diseases 
of  the  nervous  system,  manifest  diseases  of  the  brain,  hysteria,  neur- 
asthenia, and  psychoses ;  it  may  also  complicate  constitutional  dis- 
orders like  diabetes  and  Addison's  disease,  and  may  be  of  temporary 
duration  in  convalescence  from  acute  diseases,  after  serious  opera- 
tions, profuse  loss  of  fluids,  peripheral  irritation,  for  example, 
worms  (Pavy),  uterine  disorders,  and  even  syphilis,  ISTaturally,  the 
most  interesting  cases  are  those  in  which  it  occurs  as  an  independ- 
ent disease. 

Potton  *  reports  the  case  of  an  hysterical  girl  (eighteen  years  old)  who 
ate  eleven  to  twelve  times  a  clay,  and  consumed  10  to  12  kilogrammes  [22 
to  2Q^  pounds].  She  drank  little,  and  her  sleep  was  frequently  distui'bed 
to  satisfy  the  craving  for  food.  The  stools  were  never  diarrhoeal,  but 
were  frequent  and  copious;  the  urine  was  negative.  The  patient  gained 
in  weight,  but  her  strength  began  to  fail.  A  cure  was  effected  with  in- 
creasing doses  of  morphine,  up  to  0"4  gramme  [gr.  vj]  in  twenty-four 
hours.  In  a  similar  case  morphine  was  useless,  but  it  was  cured  by  large 
doses  of  opium,  up  to  3  grammes  [gr.  xlvj. 

Peyert  describes  the  case  of  a  woman,  thirty-two  years  old,  who  was 
suddenly  seized  with  a  furious  attack  of  bulimia,  so  that  she  could  not  re- 
turn home  from  the  house  of  a  neighbor  whom  she  happened  to  visit.  In 
foi'ty-flve  minutes  she  ravenously  devoured  three  i^ints  of  milk,  twenty- 
three  eggs,  and  two  pints  of  strong  wine  which  Peyer  allowed  her  to  take. 
Thereupon  she  became  quieter,  went  to  sleep,  and  awoke  perfectly  well  on 
the  nest  day.  She  described  the  attack  as  a  feeling  of  hunger  accom- 
panied by  an  inexpressible  pain  and  suffering  in  the  region  of  the  stom- 
ach ;  she  feared  that  she  would  die ;  she  did  not  feel  that  the  food  reached 
the  stomach,  and  it  did  not  relieve  her  condition ;  it  was  only  the  strong 
wine  which  affected  her. 

The  attack  had  been  preceded  by  severe  psychical  excitement  and 
worry. 

For  many  years  I  had  under  my  treatment  a  young  lawyer,  the  picture 
of  health,  normal  in  every  respect,  both  mentally  and  bodily,  but  who 

*  Potton.  Etudes  et  observations  sur  la  boulimie  dyspeptique.  Gaz.  med.  de 
Lyon,  Juin  1,  1863. 

f  A.  Peyer.  Beitrag  zur  Kenntniss  der  Neurosen  des  Magens  und  des  Darms. 
Correspondenzblatt  schweiz.  Aerzte,  1888,  No.  20. 


396  DISEASES   OF  THE  STOMACH. 

was  annoyed  with  continually  recurring  attacks  of  bulimy.  He  was  at- 
tacked whenever  be  bad  not  eaten  anytbing  for  two  or  at  most  tbree 
bours,  especially  in  tbe  morning,  wben  be  was  frequently  aroused  from 
bis  sleep.  He  was  tben  utterly  unfit  to  attend  to  any  business,  not  even 
to  follow  a  conversation.  His  whole  existence  and  every  thought  con- 
centi'ated  itself  on  the  immediate  allaying  of  his  ravenous  appetite.  A 
few  morsels  or  a  swallow  of  sti'ong  wine  sufficed  temporarily,  but  soon 
tbe  toinnent  returned  with  renewed  vigor.  Tlie  intervals  were  longest 
after  severe  bodily  exertion,  so  that  be  suffered  little  dui'ing  bis  service 
in  the  army.  But  a  sedentaiy  occupation  caused  tbe  attacks  to  be  very 
severe,  and  so  annoj"ing  that  tbe  patient  for  months  subjected  himself  to 
all  kinds  of  treatment,  including  faradization  of  the  stomach,  systematic 
lavage,  etc.,  but  unfortunately  all  without  any  ^dsible  effect;  the  best  re- 
sult was  obtained  with  large  doses  of  bi'omide  of  potassium,  but  even  this 
was  only  temporary. 

Kosenthal  gives  other  examples  associated  with  migraine,  liypo- 
chondria.  and  exophthalmic  goitre.  The  disorder  also  accompanies 
diseases  of  the  brain.  Thus,  this  author  describes  a  case  which  oc- 
curred Avith  cerebral  embolism  subsequent  to  mitral  insufficiency 
and  cardiac  hypertrophy.  In  another  case  it  was  the  result  of  con- 
cussion of  tlie  brain  ;  it  appeared  after  the  acute  symptoms  had 
disaj)peared,  and  lasted  about  three  months. 

Analogous  to  bulimy  are  the  cases  of  perverted  appetite  which 
occur  in  pregnancy,  children,  and  mental  disorders. 

Guipon*  considers  bulimia  to  be  an  abnormal  increase  of  the 
digestive  powers,  which,  in  spite  of  the  increased  consumption  of 
food,  is  unable  "  to  repair  the  deficit  in  the  economy." 

As  I  have  already  said,  on  pages  363  et  seq.,  I  do  not  think  it 
advisable  to  enter  into  speculations  about  the  site  of  this  and  other 
nem-oses.  in  so  far  as  the  more  exact  localization  is  concerned.  That 
we  are  dealing  with  central  and  not  peripheral  causes  is  proved  by 
the  simple  fact  that  any  trifle  which  is  introduced  into  the  stomach — 
a  piece  of  bread,  a  cake,  a  swallow  of  wine — may  momentarily  as- 
suage the  voracious  hunger  ;  yet  simple  appeasing  of  the  hunger  is 
out  of  the  question;  and,  furthermore,  the  feeling  may  come  on 
when  the  stomach  still  contains  large  quantities  of  food.  This  is 
also  corroborated  by  the  cases  already  cited,  in  which  the  malady 
followed  severe  cerebral  injury. 

*  Guipon.  Des  dyspepsies  boulimiques  et  syneopales.  Bull,  de  therap.,  aout 
15,  1864.  "    . 


ANOREXIA.  397 

The  necessity  of  assuming  the  existence  of  a  hunger-center,  and 
of  its  probable  situation  in  the  medulla,  has  been  made  evident  in 
the  preceding  lecture.  Rosenthal  gives  long  arguments  in  favor  of 
its  being  in  the  posterior  roots  of  the  pneumogastric  nerves,  and 
bases  his  claims  upon  a  case  of  bulbar  paralysis  reported  by  Sena- 
tor,* in  vfhicli  there  was  "  a  loss  of  the  sensation  of  satiation,"  and 
in  which  there  was  also  found  an  atrophy  of  the  posterior  nucleus 
of  the  vagus  ;  but  in  the  article  quoted  there  is  no  mention  of  a  loss 
of  the  sensation  of  satiation,  but  it  is  simply  stated  that  "  scarcely 
had  the  patient  been  fed,  but  he  again  began  to  complain  of  hunger 
and  thirst."  To  me  it  scarcely  seems  justifiable  to  infer  the  situa- 
tion of  the  hunger-center  from  this. 

The  cases  already  narrated  show  that  there  are  acute  and  chronic 
forms  of  bulimia  ;  but  the  cliief  difference  between  them  is  that  in 
the  latter  the  attacks  are  less  severe,  and  may  extend  over  weeks, 
months,  and  even  years. 

Under  these  conditions,  one  would  imagine  that  the  stomach 
is  abnormally  rapidly  evacuated,  and  that  this  is  the  cause  of  the 
feeling  of  hunger ;  but,  in  a  typical  case  of  buhmia,  reported  by 
Leo,t  which  I  had  an  opportunity  of  observing  for  some  time  at 
the  Augusta  Hospital,  on  repeated  examinations  fifty  to  ninety  min- 
utes after  the  test-breakfast,  and  more  abundant  meals,  the  stomach 
was  by  no  means  found  empty,  but,  instead,  the  amount  of  stomach- 
contents  which  could  be  expressed  was  normal.  On  the  other  hand, 
in  a  lady  under  my  care,  who  for  some  time  was  awakened  every 
two  hours  during  the  night  to  satisfy  her  ravenous  appetite,  the 
stomach  was  found  almost  empty  thirty  to  forty-five  minutes  after 
the  test-breakfast ;  the  salol  test  was  decidedly  hastened,  the  reaction 
being  present  within  thirty  minutes,  and  very  marked  after  forty- 
five  minutes.  These  two  cases  simply  show  that  there  is  no  uni- 
form condition  in  this  respect. 

Anorexia  (rj  ope^L'^,  the  desire)  denotes  a  lack  of  appetite  or  a  re- 
pugnance toward  food.     Tliese  two  conceptions  do  not  correspond 

*  H.  Senator.    Apoplectische  Bulbarparalyse  mit  wecliselstandiger  Empfindangs- 
liihraang.     Westphal's  Archiv.  Bd.  xi,  S.  713. 

t  Leo.    Verhandlungen  des  Vereios  fiir  innere  Med.    Berlin,  1889. 


398  DISEASES  OF  THE  STOMACH. 

exactly,  since  it  is  one  tiling  for  a  person  not  to  have  any  appetite, 
or  not  to  feel  hungry ;  it  is  something  else  if  there  is  a  repugnance 
toward  food,  or  even  nausea  at  the  sight  of  it.  Yet  the  latter  may 
be  regarded  as  an  exaggeration  of  the  former,  and  therefore  thej 
may  be  included  under  the  same  term. 

Anorexia  accompanies  nearly  every  dyspeptic  condition,  hut 
naturally  the  discussion  of  this  variety  of  it  is  out  of  place  when 
speaking  of  the  gastric  neui'oses.  In  the  latter,  the  loss  of  appetite 
may  arise  spontaneously,  or  may  be  due  to  hyperEesthesia  of  the 
stomach  ;  hence,  central  or  peripheral  conditions  of  irritation  may 
be  among  its  causes. 

Both  combine  to  produce  their  effects ;  the  original  anorexia, 
due  to  a  cerebral  lesion,  and  the  consequent  disturbance  of  nutri- 
tion, may  cause  hypersesthesia  of  the  stomach ;  and,  on  the  other 
hand,  the  latter  may  produce  changes  in  the  psychical  processes. 
Thus  there  is  developed  a  vicious  circle  which  may  at  times  lead  to 
the  most  serious  consequences.  In  the  first  place,  a  perverted  taste 
may  be  manifested  in  a  lack  of  desire  for  food,  which  may  at  first 
be  overcome  by  an  effort  of  the  will,  but  may  later  develop  into  a 
decided  repugnance  and  disgust  toward  food,  and  an  almost  absolute 
refusal  to  take  nourishment.  Frequently  such  patients  sit  down  at 
the  table  with  a  good  ap23etite,  or  may  even  be  very  hungry ;  yet 
the  first  bite  is  followed  by  an  insuperable  aversion  toward  eating 
any  more.  In  other  cases,  absolutely  no  need  of  taking  food  is 
experienced.  "  Unless  I  saw  how  other  people  ate,  and  were  I  not 
compelled  to  go  to  meals,  I  would  not  feel  any  need  of  it."'  is  a 
frequent  complaint  of  these  patients.  It  is  inevitable  that  the  nutri- 
tion suffers  from  this,  and  also  that  the  gastric  mucosa  becomes 
pathologically  irritable.  This  brings  us  to  the  end  of  the  circle ; 
but  then  the  hyper^sthetic  mucous  membrane  revolts  unless  the 
brain  causes  it  to  refuse  nourishment.  AVe  may  be  contented  if 
these  patients  simply  emaciate  and  look  pale  and  miserable,  pro- 
vided they  still  maintain  their  strength  ;  but.  in  the  severe  cases, 
the  condition  of  inanition  may  become  very  threatening,  so  that  the 
patients'  feebleness  may  permanently  confine  them  to  bed. 

Marked  disquiet  and  restlessness,  which  struck  Fenwick  as  being 
very  inconsistent  with  the  emaciation  of  the  patients,  did  not  occur 


ANOREXIA.  399 

in  my  cases,  yet  at  times  tliis  may  constitute  a  very  prominent  feat- 
ure of  the  disease,  Fenwick  narrates  the  case  of  a  lady  whose  rest- 
lessness led  her  to  make  absolutely  unnecessary  railway  journeys, 
although  she  knew  that  these  would  be  followed  by  severe  exhaus- 
tion and  many  days'  confinement  to  bed. 

Hyjjersesthesia  of  the  sensory  nerves  of  the  stomach  leads  to  the 
same  result,  but  in  the  opposite  way ;  for,  on  account  of  this  over- 
sensitiveness,  the  patients  gradually  eat  less  and  less  solid  food. 
Finally,  the  general  nutrition  is  disturbed,  which  also  affects  the 
higher  centers.  Not  infrequently  this  condition  may  follow  pro- 
found mental  disturbances  of  a  depressing  nature,  so  that  patients 
who  had  previously  enjoyed  excellent  health  can  positively  trace  the 
beginning  of  their  affliction  to  a  definite  period,  sometimes  even  to 
the  very  day.  The  cause  may  be  the  death  of  a  dear  friend,  deep 
grief,  crosses  in  love,  loss  of  fortune,  disgust  toward  some  particular 
article  of  food,  an  unappetizing  dish,  etc.  Frequently  the  condition 
arises  without  any  discoverable  cause.  The  majority  of  these  pa- 
tients consist  of  young  girls  of  the  better  classes ;  young  or  adult 
men  are  rarely  attacked.  As  chronic  anorexia  may  lead  to  marked 
emaciation  and  feebleness,  and,  as  Fenwick  *  claims,  even  to  death, 
it  may  be  mistaken  for  constitutional  diseases,  especially  phthisis. 
Such  errors  are  frequently  made,  and  may  occur  very  readily,  be- 
cause the  enfeebled  condition  of  these  patients  reduces  their  powers 
of  resistance,  and  they  may  therefore  be  easily  attacked  by  infectious 
germs ;  this  will  explain  their  predisposition  toM^ard  pneumonia, 
pleurisy,  acute  bronchitis,  etc.  Hence  a  thorough  examination  of 
the  heart  and  lungs  is  very  important,  and  should  never  be  neglected. 
On  the  other  hand,  tuberculosis  develops  much  less  frequently  than 
one  would  expect.  I  have  now  observed  three  young  girls  suffering 
from  severe  nervous  anorexia  for  periods  of  six,  four,  and  three 
years  respectively  ;  they  are  in  bed  during  the  greater  part  of  the 
year  ;  there  have  been  fluctuations  in  the  general  condition,  tempo- 
rary improvement,  either  spontaneously  or  after  a  sojourn  at  the 
spas,  or  during  some  new  course  of  treatment ;  but,  taken  all  in  all, 


*  Fenwick,     On  Atrophy  of  the  Stomach  and  on  the  Nervous  Affections  of  the 
Digestive  Organs.     London,  1880,  p.  99. 


400  DISEASES  OF  THE  STOMACH. 

the  condition  is  about  the  same,  without  any  definite  cure,  yet  with- 
out any  other  marked  complications.  We  may  dispose  of  such  cases 
under  the  generic  expression  of  "  hysteria,"  but  this  by  no  means 
alters  the  fact  that  it  is  a  sad  affliction  for  the  patients,  and  especially 
for  their  relatives. 

Gastralgia  or  Gastrodynia  *  (??  ohvvrj,  pain).  Although  the  causes 
of  pain  in  the  stomach  are  very  manifold,  yet  its  manifestation  is 
quite  uniform.  This  is  perfectly  rational,  because  the  pain  is  always 
due  to  an  irritation  of  the  sensory  fibers  of  the  vagus,  either  in  its 
peripheral  terminal  filaments,  or  nucleus,  or  in  the  reflections  to  it 
from  still  higher  centers.  Hence  gastralgia  may  be  due  to  local 
causes,  or  to  conditions  of  irritation  in  the  nerves  outside  of  the 
stomach. 

The  attacks  of  pain  may  be  ushered  in  by  a  feeling  of  discom- 
fort, fullness  and  tension  in  the  epigastrium,  or  they  may  begin  sud- 
denly and  reach  their  greatest  intensity  almost  instantly.  JSTot  in- 
frequently the  scene  may  be  opened  with  a  copious  secretion  of 
saliva ;  Oser  mentions  a  case  in  which  the  attacks  began  almost  uni- 
formly with  a  severe  toothache.  But  the  pain  in  the  left  ear,  which 
is  mentioned  by  this  author  among  the  initial  symptoms,  is  surely  to 
be  regarded  as  a  coincidence.  The  character  of  true  gastralgia  is  an 
agonizing  boring  or  cutting  pain,  sometimes  sharply  localized,  some- 
times diffuse,  or  even  resembling  a  girdle  sensation ;  in  severe  cases 
the  intensity  is  very  pronounced.  Instinctively  the  patients  double 
themselves  up  to  relax  the  abdominal  muscles,  breathe  superficially, 
and  carefully  avoid  coughing  and  speaking  aloud.  Although  there 
is  decided  cutaneous  hypersesthesia  of  the  abdominal  parietes,  yet 
deep  pressure  often  gives  relief.  The  face  is  pale,  distorted  with 
pain,  and  covered  with  cold  sweat,  and  there  may  be  conditions  of 
collapse  with  an  intense  sensation  of  impending  death,  and  attacks 
of  unconsciousness.  The  abdominal  aorta  pulsates  vigorously,  and 
pains  radiate  along  the  spinal  column  and  into  the  intercostal  spaces. 
At  times  points  of  exquisite  tenderness  may  be  demonstrated  along 
the  spinal  column  or  the  lumbar  nerves. 

*  I  avoid  the  expression  cardialgia,  because  it  localizes  the  pain  at  a  definite  spot 
in  the  stomach  without  our  being  able  to  prove  it. 


GASTRALGIA.  401 

In  its  general  features  and  duration  tlie  gastralgic  attack  is  very 
variable  ;  the  paroxysms  may  be  either  brief  and  mild  or  may  last 
for  hours,  and  may  torture  the  sufEerer  till  medical  aid  or  I^ature 
brings  relief.  As  a  rule,  the  attack  wears  itself  out  and  the  normal 
condition  is  gradually  restored  ;  at  other  times  it  terminates  sud- 
denly with  vomiting ;  or  the  patient,  to  whom  every  morsel  would 
have  been  a  horror  only  a  short  time  before,  now  experiences  sharp 
hunger  and  demands  food  after  the  attack  is  over.  The  urine  passed 
after  the  paroxysm  usually  has  a  low  specific  gravity.  A  feeling  of 
marked  relaxation  and  exhaustion  is  left  behind.  Happily,  these  at- 
tacks do  not  recur  frequently,  yet  I  have  seen  a  case  in  which  there 
were  three  or  four  in  one  day,  causing  very  profound  exhaustion  of 
the  patient. 

The  etiology  of  gastralgia  is  very  varied  and  may  be  classified  as 
follows : 

1.  Local  Causes  (true  gastralgia). — In  the  chapter  on  gastric  ulcer 
I  mentioned  the  fact  that  there  are  follicular  inflammations,  haemor- 
rhages, and  losses  of  substance  of  the  mucous  membrane  which  are 
not  manifested  by  the  classical  symptoms  of  ulcer  of  the  stomach, 
but  which  give  only  a  single  symptom,  recurring  gastralgia  which, 
although  it  does  not  appear  after  every  meal,  yet  stands  in  some 
relation  to  taking  food,  l^ow,  it  is  characteristic  of  nervous  gas- 
tralgia that  it  has  nothing  at  all  to  do  with  eating  ;  therefore,  strictly 
speaking,  these  cases  just  spoken  of  do  not  belong  here ;  yet  we 
must  not  classify  too  strictly  on  either  side,  because  every  experi- 
enced physician  has  seen  cases  in  which  these  criteria  could  not  be 
applied.     The  following  is  an  example  : 

Miss  von  B.,  from  D ,  twenty-one  years  old;  complained  of  gas- 
tralgic pains  which  recurred  irregularly  for  about  six  months.  Some- 
times they  stay  away  for  weeks ;  at  other  times  they  recur  every  few  days. 
A  relation  of  these  attacks  to  taking  food  was  at  times  suspected,  but  not 
constantly  present.  They  have  frequently  occurred  very  early  in  the 
morning,  and  have  aroused  her  from  her  sleep ;  the  pain  was  localized  in 
the  stomach  or  the  infrasternal  depression,  and  was  not  very  severe.  No 
history  of  ulcer;  never  had  migraine;  the  acidity  of  the  filtrate  after  the 
test-breakfast  was  66  per  cent — i.  e.,  just  at  the  upper  limits  of  the  nor- 
mal; contains  no  abnormal  constituents.  Physical  examination  negative. 
No  tenderness  over  the  ovaries,  no  painful  points  on  pressure.  Although 
the  patient  did  not  look  bad,  yet  recently  she  had  lost  constantly  in 
weight.     The  continuous  frequency  of  the  attacks  during  the  past  few 


402  DISEASES  OF  THE  STOMACH. 

weeks  led  her  to  come  to  Berlin  for  treatment.     Diagnosis :  follicular  ul- 
ceration of  the  mucous  membrane  of  the  stomach.     A  rest-cure  ordered. 

The  patient  left  the  sanitarium  after  four  weeks,  during  which  time 
she  had  gained  four  kilogrammes  [about  nine  pounds],  and  without  hav- 
ing had  any  attacks  during  the  last  fortnight.  Soon  after  she  was  mar- 
ried, and  according  to  subsequent  reports  has  remained  free  from  attacks 
ever  since. 

In  cases  like  the  above,  in  spite  of  the  apparently  idiopathic  gas- 
tralgia,  there  are  distinct  anatomical  lesions.  There  is  another  group 
of  gastralgias  which,  although  distinctly  neurotic,  yet  are  only  indi- 
rect, since  the  real  lesion  is  a  neurosis  which  consists  in  hypersecre- 
tion of  gastric  juice,  concerning  which  I  will  speak  later.  It  is 
evident  that  the  very  acid  chyme  irritates  the  gastric  nerves,  and 
thus  causes  typical  attacks  of  gastralgia,  for  which  no  other  cause 
than  this  can  be  found. 

Thus  the  class  of  genuine  gastralgias  is  restricted  to  a  very  small 
gronp.  My  own  experience  leads  me  to  be  very  sjDaring  of  the 
diagnosis  of  idiopathic  gastralgia,  and  I  believe  that  many  of  the 
cases  grouped  mider  this  heading  would  be  differently  classed  if 
they  were  examined  according  to  our  modern  methods. 

2.  Gastralgias  due  to  Diseases  of  the  Central  Nervous  System. — 
Diseases  of  the  brain  are  manifestly  very  infrequently  accompanied 
by  pains  in  the  stomach  ;  according  to  Rosenthal,  only  a  few  vague 
data  are  given  by  Krukenberg.  They  are  much  more  frequent  in 
spinal  diseases.  The  gastric  crises  of  tabes  were  first  described  by 
Charcot ;  and,  after  attention  had  been  draw^n  to  them  by  this  dis- 
tinguished French  clinician,  they  have  frequently  been  discussed. 
Their  clinical  existence  having  been  established,  the  pathological 
basis  was  foimd  to  consist  in  a  sclerotic  degeneration  of  the  vagus 
nucleus  or  the  vagus  trunk ;  this  has  been  demonstrated  in  numer- 
ous recent  papers  by  Kahler,  Demange,  Landouzi  and  Dejerine, 
Oppenheim,  and  others. 

Although  Delamare  *  (1866)  was  the  first  to  carefully  study  these 
attacks — for  analogous  cases  were  reported  by  Gullf  as  early  as 
1856 — yet  it  is  due  to  Charcot  and  his  school  that  the  existence  of 

*  Delamare.  Des  troubles  gastriques  dans  I'ataxie  locomotrice.  These  de  Paris, 
1866. 

t  W.  Gull.     Cases  of  Paraplegia.     Guy's  Hospital  Reports,  1856,  p.  161. 


GASTRALGIA.  403 

the  affection  lias  been  firmly  established,  and  it  is  therefore  no  more 
than  right  to  attach  his  name  to  the  gastric  crises.  I  can  not  resist 
the  temptation  to  give  Charcot's  classical  description  of  such  crises :  * 
"  Suddenly,  and  frequently  with  an  attack  of  fulgurating  pains,  the 
patient  complains  of  pains  which  begin  in  the  groins,  ascend  along 
both  sides  of  the  abdomen  to  the  epigastrium,  where  they  become 
fixed.  There  are  also  pains  between  the  shoulders,  which  radiate 
like  lightning  to  the  buttocks.  The  heart-action  is  raj^id  and  forci- 
ble ;  but  there  is  no  rise  in  temperature.  At  the  same  time  there  is 
almost  uninterrupted  and  exceedingly  ]3ainful  vomiting  ;  the  vomit 
consists  at  first  of  food,  later  of  a  mucous  fluid,  which  is  sometimes 
mixed  with  bile  or  tinged  with  blood.  This  is  accompanied  by 
marked  nausea  and  vertigo,  as  well  as  by  cardialgic  j^ains  w^hich  at 
times  reach  a  terrible  degree  of  intensity.  These  gastric  pains  may 
continue  almost  uninterruptedly  for  two  or  three  days.  They  may 
apj)ear  at  the  very  beginning  of  the  disease,  and  then  belong  to  the 
so-called  preataxic  symptoms,  but  they  may  not  disappear  even  when 
the  disease  has  reached  its  full  development  with  complete  ataxia." 

The  frequency  of  the  attacks  is  variable :  sometimes  there  are 
long  free  periods,  and  the  occurrence  of  the  crises  is  irregular ;  at 
other  times  they  recur  monthly,  w^eekly,  or  even  at  still  shorter  in- 
tervals ;  they  may  even  seem  to  assume  a  certain  regular  type.  A 
characteristic  feature  is  the  sudden  transition  from  the  condition  of 
intense  pains  and  complete  cessation  of  all  the  functions  of  the 
stomach  to  one  of  absolute  comfort,  so  that  the  patients  ask  for  food 
a  short  time  after  the  close  of  the  crisis. 

Examination  of  the  stomach-contents  before,  during,  and  after 
the  attack  has  not  revealed  anything  which  is  characteristic,  since 
the  degrees  of  acidity  w^hich  were  found  were  very  variable,  and 
stood  in  no  relation  to  the  course  of  the  crisis.  Having  made  nu- 
merous examinations  myself,  I  can  co^rroborate  these  facts,  which 
were  first  announced  by  von  J^oorden.f 

But  gastralgias  may  be  caused  not  alone  by  sclerosis  of  the  pos- 

*  Charcot.  Legons  sur  les  maladies  du  systeme  nerveux,  1881,  tomes  i,  p.  261, 
et  ii,  p.  32. — Des  crises  gastriques  tabetiques,  etc.  Gazette  medic,  de  Paris,  1889, 
No.  39. 

f  Von  Noorden.     Pathologie  der  gastrischen  Krisen.     Charite  Annalen,  1890. 
26 


404:  DISEASES   OF  THE  STOMACH. 

terior  columns,  but  also  by  other  lesions  wliicli  involve  the  vagus 
nucleus.  Thus  Leyden  includes  them  among  the  symptoms  of  sub- 
acute myelitis ;  Oser  saw  tliem  in  a  case  of  pressure  myelitis  follow- 
ing vertebral  caries.* 

These  gastralgias  would  always  be  interesting  to  us,  even  if  they 
were  simply  symptoms  of  tabes  in  the  stage  of  complete  devel- 
oj^ment ;  but  gastric  crises  are  not  infrequently  the  initial  symptom 
of  locomotor  ataxia.  This  lends  a  peculiar  importance  to  them ; 
hence  in  every  ca-^e  of  nervous  gastralgia  a  thorough  examination 
should  be  made  rn  this  direction,  and  frequently  enough  we  may 
discover  qther  symptoms  of  the  disease  which  had  not  been  noticed 
by  the  patient.     Rosenthal  gives  a  typical  example  of  this  : 

After  very  fatiguing  exertions  a  man,  thirty-eight  years  old,  claimed 
that  he  was  seized  with  pains  in  the  lumbar  region,  weariness  in  the  legs 
after  slight  efforts,  and  frequent  severe  cramps  in  the  stomach.  A  con- 
sultant declared  the  case  to  be  one  of  spinal  irritation,  and  advised  the 
application  of  a  magnet  to  the  spinal  column,  and  later  over  the  stomach. 
The  gastric  irritation  was  not  overcome  by  the  m.agnetism,  but  developed 
into  intense  periodical  attacks  of  cardialgia  accompanied  by  syncoj)e, 
severe  vomiting,  increased  rapidity  of  the  pulse  (up  to  120  beats  per  min- 
ute), and  painful  contractions  of  the  extremities.  The  attacks  lasted  six 
to  eight  days.  The  stomach  trouble  was  diagnosticated  as  gastritis,  and  a 
suitable  medical  and  mechanical  treatment  was  instituted,  but  without 
any  marked  result. 

These  were  the  statements  of  the  physician  who  brought  the  case  to 
me  in  the  fall  of  1879.  On  examination  I  found  lessened  sensitiveness  of 
the  spinal  column  toward  mechanical  and  electrical  stimulation,  marked 
diminution  of  the  electro-cutaneous  irritability  of  the  legs,  and  loss  of  the 
sensibility  of  the  skin.  The  hairs  on  the  thighs  could  be  pulled  out  in 
bundles  without  any  pain ;  the  patellar  reflex  was  absent  on  both  sides. 
The  stomach  was  painful  on  pressure  toward  the  fundus,  but  was  not  en- 
larged ;  the  appetite  was  good.  On  questioning  the  patient,  he  stated  that 
at  times  he  had  formerly  had  double  vision,  but  it  was  only  recently  that 
he  had  been  attacked  with  pains,  sometimes  boring,  sometimes  f  ulgru'at- 
ing.  I  diagnosticated  tabes  with  gastric  crises,  and  recommended  mild 
galvanic  and  hydriatic  treatment.  In  later  years  ataxia,  paralysis  of  the 
bladder,  and  impotence  were  developed  ;  the  patient  finally  died  with 
symptoms  of  mental  disturbances. 

I  myself  have  had  the  opportunity  of  seeing  many  cases  which 
had  previously  been  treated  for  gastralgia,  without  any  result,  by 
stomach  specialists ;  yet  I  found  typical  symptoms  of  tabes,  absence 

*  Oser,  loc.  cit.,  p.  42. 


GASTRALGIA.  405 

of  patellar  reflexes,  anfestliesiiie  and  parsestliesige,  and  in  one  case 
even  Romberg's  symptom. 

Here  I  may  also  classify  the  condition  wliicli  Biicli  *  has  de- 
scribed as  a  separate  form  of  nervous  disorder  nnder  the  name  of 
"•  Wirbelweh^''  [vertebral  pain] — i.  e.,  the  pains  which  are  produced 
Ijy  pressure  made  in  the  epigastrium,  or  at  the  level  of  the  umbili- 
cus, upon  the  anterior  surface  of  the  lumbar  vertebrae.  They  are 
usually  accompanied  by  a  subjective  feeling  of  more  forcible  pulsa- 
tion of  the  abdominal  aorta  ;  they  do  not,  however,  occur  if  pressure 
is  made  on  both  sides  alongside  of  the  vertebral  column.  At  times, 
though  not  always,  the  spinous  processes  are  also  sensitive.  Among 
the  accompanjaug  symptoms  are  nausea,  eructation,  ravenous  appe- 
tite, with  nausea  and  languor.  The  stools  are  variable  ;  constipation 
is  the  rule,  although  diarrhoea  may  occur. 

Bnch  correctly  assumes  this  condition  to  be  a  neurosis  of  the 
sympathetic  plexus  which  proceeds  from  the  plexus  aorticus  abdomi- 
nalis  and  the  plexus  hypogastricus,  and  supplies  the  bodies  of  the 
vertebrse  and  the  intervertebral  disks  with  nerve-filaments.  But  this 
condition  was  recognized  long  ago,t  and  is  also  mentioned  by  me 
on  page  407,  among  the  symptoms  of  gastralgia.  It  remains  ques- 
tionable whether  these  cases  ought  to  be  grouped  in  a  separate  class. 
Buch  claims  to  have  had  good  effects  from  injections  of  antipyrin 
in  loco  affecto  /  but  this  is  rendered  doubtful,  because  at  the  same 
time  he  also  used  all  the  usual  means  of  physiatric  treatment,  in- 
cluding cold  rubbings,  douches,  baths,  gymnastics,  diet,  etc. 

3.  Gastralgias  from  Constitutional  Causes. — These  include  the 
cases  occurring  in  neurasthenia,  hysteria,  certain  psychoses,  and  pri- 
mary anaemia. 

It  is  important,  not  alone  for  the  semeiology,  but  also  for  the 
prognosis,  that  neurasthenia  be  distinguished  from  hysteria,  and,  as 
this  will  not  be  accomplished  by  the  epigram  that  "  neurasthenia 
includes  rational  sensations,  hysteria  those  which  are  irrational,"  I 
shall  therefore  endeavor  to  distinguish  these  two  conditions  in  the 


*  Buch.  Wirbelweh,  eine  iieue  Form  der  Gastralgia.  St.  Petersburger  med. 
Wochenschr.,  1889,  No.  22. 

f  Hornbaum.  Ueber  die  Pulsation  in  der  Oberbauchgegend  als  begleitendes 
Symptom  der  Indigestion.     Hildburgshausen,  1836. 


406  DISEASES   OP   THE   STOMACH. 

following,  in  so  far  as  it  is  essential  for  the  gastric  manifesta- 
tions. 

Neurasthenic  G-astralgias. — The  expression  asthenia  was  intro- 
duced by  Brown,  and  was  later  applied  by  Broussais  in  the  doctrine 
of  irritants  ;  it  denotes  a  condition  of  weakness  of  an  organ  Avhich 
is  at  first  manifested  by  a  morbidly  increased  irritability,  and  later 
by  a  diminution  of  its  functional  activity.  Therefore,  the  term 
neurasthenia  indicates  an  enfeebled  condition  of  the  nervous  system 
and  the  consequences  thereof.  It  is  marked  by  a  continuous  and 
advancing  course,  and  seldom  occurs  without  causal  factors  of  an 
enfeebling  nature,  mental  overexertion,  strong  emotions,  sexual  ex- 
cesses, anaemic  conditions,  etc. 

Rosenthal  draws  a  sharp  distinction  between  the  irritative  and 
depressive  forms,  the  former  being  recognized  by  manifestations 
which  are  pre-eminently  those  of  irritation ;  the  latter  by  symptoms 
of  exhaustion.  Both  are  related  to  each  other  by  numerous  tran- 
sitional forms,  and  are  characterized  as  follows  by  this  experi- 
enced neurologist :  "  The  patients  suffering  from  irritative  neuras- 
thenia complain  of  diffuse  or  circumscribed  headache,  which  is 
associated  (especially  in  an  attack)  with  local  cutaneous  hyperalgia 
and  acoustic  or  optic  hypersesthesia.  Marked  mental  excitability, 
uncalled-for  depression  of  spirits,  and  sensations  of  fear  and  ina- 
bility to  speak  or  read  for  a  prolonged  period,  indicate  unusual 
central  irritability  and  exhaustion.  Equally  annoying  to  the  pa- 
tients are  the  periodical  pains  in  the  spine,  with  -points  douloureux 
in  the  nape  of  the  neck,  more  frequently  between  the  scapulae,  less 
often  lower  down.  Electrical  and  thermal  stimulation  also  causes  a 
peculiar  sensitiveness  here,  especially  over  the  spinous  and  trans- 
verse processes.  This  secondary  condition  of  irritation  in  the  dis- 
tribution of  the  sensory  roots  may  be  demonstrated  more  accurately 
and  positively  by  means  of  electricity.  Most  frequently  I  found  a 
striking  sensitiveness  on  the  left  side  toward  cathodal  irritation  and 
the  faradic  brush  which  extended  like  half  a  girdle  over  the  points 
douloureux  in  its  path,  and  over  which  it  was  most  pronounced. 
Yague  neuralgias  or  parasthesise  in  the  upper  and  lower  extremi- 
ties, becoming  easily  tired  and  exhausted  after  exercise  and  work, 
noticeable  increase  of  the  cutaneous  and  patellar  reflexes,  as  well  as 


NEURASTHENIC   GASTRALGIA.  407 

disturbances  of  sleep  and  appetite,  constitute  many  of  the  patlio- 
logical  variations  of  irritative  neurasthenia.  When  located  in  the 
chest,  periodical  cardialgias  are  frequently  present.  We  may  also 
often  observe  that  increase  of  the  pain  in  the  back,  and  of  the  ten- 
derness over  the  cervical  and  dorsal  vertebrae,  together  with  fullness 
of  the  head,  are  the  forerunners  of  the  periodically  recurring  gas- 
tralgia.  Not  infrequently  there  are  also  localized  hypergesthetic 
areas  on  the  trunk,  and  jiuncta  dolorifica  may  be  more  prominent 
as  well  as  more  abundant.  More  or  less  rapidly  these  are  now  fol- 
lowed by  pain  in  the  stomach,  the  intensity  of  which  gradually  in- 
creases. 

"  The  pain  is  characterized  sometimes  as  '  drawing  together,' 
sometimes  as  boring,  and  radiates  from  the  lower  ribs  to  the  epigas- 
trium ;  it  is  accompanied  by  the  vaso-motor  symptoms,  and  those 
due  to  the  cerebral  anaemia,  which  have  already  been  described. 

"  The  dejpressive  form  of  neurasthenia  presents  itself  thus  :  The 
patients  complain,  especially  after  eating,  of  an  oppressive  sensation 
or  a  dragging  which  extends  from  the  stomach  into  the  abdomen, 
without,  however,  having  the  paroxysmal  character  of  the  painful 
gastralgias.  The  pain  in  the  back  is  also  not  so  intense,  nor  is  it  of 
so  neuralgic  a  character ;  on  the  other  hand,  the  motor  exhaustion, 
sexual  weakness,  seminal  emissions,  mental  depression,  and  atonic 
dyspepsia  are  especially  predominant.  The  diagnosis  of  a  localized 
spinal  meningitis,  which  is  not  infrequently  resorted  to,  may  be 
avoided  by  observing  that  in  the  latter  the  intense  and  usually 
widely  distributed  pain  in  the  back  is  ushered  in  by  fever,  tonic 
contractions  of  the  muscles  of  the  nape  of  the  neck  and  the  back 
prevent  any  movements,  contractures  and  partial  paralyses  may 
occur  in  the  extremities,  and  finally  pain  in  the  stomach  is  extremely 
rare  and  temporary." 

To  this  description  I  must  add  Burkart's  painful  2:>oints.*  On 
pressing  deeply  down  to  the  retroperitonseum,  over  the  region  of 
the  superior  hypogastric,  aortic,  and  coeliac  plexuses,  the  patient 
experiences  exceedingly  sharp  and  unpleasant  pains,  which  radiate 
up  to  the  epigastrium.     Burkart  claims  to  have  found  these  points 

*  R.  Burkart.     Zur  Pathologic  der  Nearasthenia  gastrica.     Bonn,  1882. 


408  DISEASES   OP  THE   STOMACH. 

in  all  cases.  In  1884,  in  the  discussion  on  nervous  dyspepsia  at  tlie 
third  Congress  for  Internal  Medicine,*  I  stated  that  in  my  expe- 
rience this  was  not  always  the  case.  Kichter  f  also  asserts  that,  as  a 
rule,  pressure  over  the  stomach  and  abdomen  is  not  painful.  Since 
then,  this  has  been  agreed  to  by  others.  At  that  time  I  said  that 
the  same  was  true  of  the  above-mentioned  painful  points  along  the 
spinal  column,  upon  which  so  much  stress  was  laid  by  Rosenthal. 
They  may  be  present  (according  to  Rosenthal,  in  75  per  cent  of  the 
cases),  or  they  may  be  absent ;  but,  even  if  they  are  present,  they 
have  no  important  bearing  on  the  conception  of  the  disease,  and  are 
by  no  means  one  of  its  essential  features.  On  the  contrary,  I  will 
say  that  my  further  experience  has  been  that  pain  along  the  spinal 
column,  both  on  pressure  and  with  the  faradic  brush,  may  fre- 
quently be  absent  in  undoubted  cases  of  neurasthenia.  I  shall  cite 
such  a  case  of  Rosenthal,  to  compare  it  with  one  of  my  own : 

A  man,  thirty-two  years  old,  says  that  three  years  previously  he  took 
cold  while  going  home  one  morning  after  a  night  of  dissipation.  Soon 
after  he  felt  a  steadily  increasing  pain  in  the  stomach.  The  pain  was  de- 
scribed as  glowing  and  boring,  radiating  frequently  from  the  lower  ribs 
to  the  epigastrium,  and  causing  him  to  "  double  up  "  and  moan  loudly. 
The  countenance  was  pallid  and  covered  with  clammy  sweat,  the  hands 
and  feet  were  cold,  and  the  pulse  small  and  tense.  The  attacks  recurred 
frequently,  especially  in  the  early  part  of  the  evening,  lasted  for  hours, 
and  on  their  termination  the  patient  fell  asleep  exhausted.  The  attacks 
varied  in  intensity,  but  neither  the  quality  nor  the  quantity  of  food  had 
any  influence  upon  them.  The  condition,  which  was  sometimes  consid- 
ered gastric  ulcer,  at  others  biliary  colic,  resisted  all  the  usual  remedies  ; 
no  marked  improvement  followed  even  after  daily  washing  out  of  the 
stomach  and  the  methodical  drinking  of  the  water  of  the  Milhlbrunnen 
at  Carlsbad. 

A  gastroscopic  examination  was  made  by  Dr.  Mikulicz,  but  no  struct- 
ural changes  could  be  discovered.  The  stomach-contents  were  pumped 
out,  but  were  found  to  have  normal  acidity  and  digestive  powers.  Biliary 
colic  was  excluded  on  account  of  the  normal  size  of  the  liver,  the  absolute 
lack  of  tenderness,  no  icteric  discoloration  of  the  skin  and  the  urine,  as 
well  as  the  absence  of  a  febrile  movement  during  the  attacks.  Again,  the 
relief  afiPorded  during  the  paroxysms  by  deep  pressure  over  the  stomach, 
the  typical  spontaneous  origin  of  the  pain,  which  was  never  caused  by 
eating  even  very  indigestible  substances,  as  well  as  the  non-appearance  of 
digestive  disturbances  and  vomiting — all  these  could  not  be  reconciled  with 

*  Verhandlungen  des  Congresses  ftir  innere  Medicin,  1884,  S.  232. 
f  Richter.     Ueber  nervosa  Dyspepsie  und  nervosa  Enteropathie.     Berliner  klin. 
Wochenschr.,  1882,  No.  13. 


NEURASTHENIC   GASTRALGIA.  409 

a  diagnosis  of  gastric  ulcer.  For  the  same  reasons  renal  colic,  disorders 
of  the  pancreas  and  the  like,  which  sometimes  cause  cardialgia,  were  also 
excluded.  Ou  the  other  hand,  the  constant  presence  of  painful  spots 
along  the  vertebral  column,  the  hyperalgias  which  could  be  traced  along 
the  intercostal  nerves  to  the  epigastrium,  the  diffuse  occurrence  of  mus- 
cular spasms  in  various  parts  of  the  body,  the  marked  increase  of  the  ten- 
don reflexes,  the  pale-yellow  color  of  the  patient,  together  with  his  un- 
usual psychical  irritability,  indicated  gastric  neuralgia  upon  a  neuras- 
thenic hasis. 

The  change  in  the  diagnosis  was  followed  by  a  corresponding  altera- 
tion of  the  therapy.  Local  treatment  was  entirely  avoided  ;  a  nutritious 
diet,  including  even  beer,  was  ordered;  the  abnormal  irritability  of  the 
ceutei'S  was  lessened  by  large  doses  of  bromide  of  potassium,  3  to  4 
grammes  [gr.  xlv-lx],  with  one  gramme  [gr.  xv]  of  bicarbonate  of  soda 
morning  and  evening.  To  combat  the  anaemia,  ferrum  pyrophosphori- 
cum  cum  natrio  citrico  (Ph.  Austr.)  was  given  after  the  midday  meal  (as 
much  as  would  go  on  the  point  of  a  knife).  During  the  two  days  follow- 
ing he  felt  only  a  touch  of  the  pains  in  the  stomach,  after  which  they  did 
not  return  ;  the  medication  was  kept  up  a  fortnight  longer.  He  was 
watched  for  six  weeks  more,  but  remained  without  the  slightest  dis- 
turbance. 

My  case  (the  only  one  of  this  kind  which  has  come  under  my 
observation)  was  as  follows  : 

In  August,  1885,  a  merchant,  forty-five  years  old,  was  brought  to  me 
by  his  family  physician.  He  complained  of  great  fatigue,  especially  a 
feeling  of  heaviness  in  his  legs,  disinclination  for  work,  and  dullness  and 
confusion  of  the  head,  especially  after  eating.  His  appetite  was  capri- 
cious, and  he  never  dared  to  eat  the  same  thing  many  times  in  succession. 
For  the  past  six  weeks  he  had  sufl'ered  severely  from  painful  attacks  of 
gastralgia,  which  at  first  were  far  apart,  but  later  occurred  daily,  and 
sometimes  even  several  times  a  day.  Although  they  did  not  occur  imme- 
diately after  eating,  yet  he  thought  that  they  were  caused  by  eating,  and 
consequently  had  restricted  his  diet  ;  as  a  result  he  lost  over  ten  pounds 
in  weight.  A  course  of  treatment  for  three  weeks  at  Carlsbad  had  not 
alone  not  benefited  him,  but  had  even  made  him  much  worse.  The 
bowels  were  constipated.  The  patient,  a  very  active  person,  well  nour- 
ished but  pale,  was  the  proprietor  of  a  very  large  factory  employing  over 
one  hundred  people,  a  number  of  whom  were  engaged  outside  of  Berlin  ; 
he  had  to  oversee  many  of  their  trips,  and  consequently  was  frequently 
aggravated  and  worried.  The  illness  of  his  partner  for  a  time  threw  the 
entire  responsibility  upon  him.  A  year  previously  he  had  had  a  similar 
attack. 

The  physical  examination  revealed  no  abnormalities  ;  all  signs  of 
spinal  and  intercostal  neuralgias,  as  well  as  painful  points,  were  absent. 
On  the  other  hand,  the  tendon  reflexes  were  markedly  increased.  The 
chemical  processes  of  the  stomach  (after  the  test-breakfast)  were  found 
normal. 

At  the  flret  glance  it  was  apparent  that  this  was  a  tolerably  clear  case 


410  DISEASES   OP   THE  STOMACH. 

of  nervous  gastralgia,  in  spite  of  tlie  absence  of  the  painful  points,  the 
symptom  upon  which  so  much  stress  had  been  laid.  The  treatment  con- 
firmed the  diagnosis.  At  first  bromide  of  potassium  was  used  ;  later  a  so- 
journ for  several  weeks  at  one  of  the  resorts  on  the  Baltic  Sea  caused  the 
cessation  of  the  attacks,  and  the  patient  then  gained  rapidly  in  weight. 
The  rest  was  accomplished  by  a  proper  diet  and  hygienic  measures  (daily 
sponging  and  riding).  Up  to  the  present  time  the  attacks  have  not  re- 
curred. 

I  must  not  omit  to  mention  how  difficult  it  is  in  such  cases,  as 
is  well  shown  in  the  case  of  Rosenthal,  to  exclude  the  presence  of 
biliary  colic.  Even  in  that  case  this  point  is  not  definitely  settled. 
Undoubtedly,  there  are  cases  of  biliary  colic  without  icterus,  swell- 
ing of  the  gall-bladder,  and  febrile  movement,  and  in  whicli  the 
diagnosis  between  an  affection  of  the  liver  and  the  stomach  can  not 
be  made.  Among  ten  cases  of  pure  gastralgia  under  my  care  no 
less  than  four  are  marked  with  an  interrogation  point.  The  follow- 
ing may  be  quoted  as  an  example : 

A  well-nourished  woman,  thirty  years  old,  the  mother  of  seven  chil- 
dren, had  formerly  never  had  pain  in  the  stomach  ;  five  years  previously, 
after  the  birth  of  the  fifth  child,  had  "  biliary  colic  "  ;  had  been  to  Carls- 
bad twice  and  obtained  relief  ;  for  the  past  year  has  had  painful  cramps 
in  the  stomach,  at  first  infrequently,  lately  every  fortnight.  Physical  ex- 
amination was  negative.  The  uterus  was  pronounced  normal  by  a  gyn- 
aecologist. Never  had  belching  or  vomiting  ;  between  the  attacks  the 
appetite  was  good.  The  bowels  are  constipated  after  the  attacks,  other- 
wise regular.  Although  considerable  relief  was  afi'orded  by  regulating 
the  diet,  drinking  the  water  of  the  Marienbader  Kreuzbrunnen,  and 
taking  soda  to  which  small  doses  of  morphine  had  been  added ;  yet,  dur- 
ing the  two  months  in  which  the  patient  was  under  my  observation,  she 
still  had  occasional  attacks,  although  less  severe  in  character.  I  consid- 
ered the  diagnosis  doubtful,  in  spite  of  the  fact  that  the  patient  no  longer 
referred  the  pain  to  the  right  hypochondrium  as  formerly,  but  to  the 
middle  line,  and  even  to  the  left  of  it  ;  the  reason  was,  that  we  know  that 
attacks  of  biliary  colic  may  be  followed  by  inflammation  of  the  gall-blad- 
der, with  the  subsequent  formation  of  adhesions  to  the  adjacent  viscera, 
the  stretching  of  which  may  produce  colicky  pains. 

Hysterical  Gastralgias. — It  is  only  the  peculiar  nature  of  hys- 
teria which  will  enable  us  to  recognize  as  hysterical  the  attacks  of 
gastralgia  which  may  occur  during  its  course. 

In  the  following  remarks  I  do  not  by  any  means  propose  to  give 
a  thorough  description  of  the  protean  picture  of  hysteria  ;  I  simply 
wnsh  to  give  a  few  suggestions,  upon  the  completeness  of  which  I 


HYSTERICAL   GASTRALGIA.  411 

lay  very  little  stress,  because  the  characteristic  features  of  this  dis- 
ease are  not  difficult  to  recognize. 

In  this  affection,  unlike  neurasthenia,  the  psychical  factors,  per- 
verse thoughts  and  sensations,  occupy  a  pre-eminent  place.  The  tend- 
ency toward  extraordinary  behavior,  the  conscious  or  unconscious 
longing  to  be  conspicuous  by  any  means  whatsoever,  the  turning 
away  from  every  serious  occupation,  the  degradation  into  the  peculiar, 
fantastic  existence  about  which  the  patient's  entire  being  revolves, 
the  capricious,  willful,  and  impulsive  actions  are  not  those  of  ordi- 
nary life,  and  these  are  all  aberrations  from  normal  thought  and  sen- 
sation, denoting  profound  changes  in  the  psychical  processes.  As- 
sociated with  them  are  the  manifold,  objectively  demonstrable  nerv- 
ous disturbances,  convulsions,  paralyses,  pupillary  inequalities,  liemi- 
ansesthesise,  and  changes  in  electrical  sensibility.  The  manifestations 
of  transference  give  additional  symptoms.  In  the  affections  with 
gastric  disturbances  I  have  been  particularly  struck  by  the  absence 
or  lessening  of  the  electro-cutaneous  sensitiveness  of  the  abdominal 
parietes  ;  this  sign  was  not  absent  even  where  other  hysterical  symp- 
toms were  scarcely  manifested.  A  marked  example  of  this  is 
afforded  in  the  following  history  which  I  shall  relate  in  the  exact 
words  of  the  physician  who  sent  the  case  to  me : 

"  The  patient  is  a  lady,  fifty-two  years  of  age,  the  history  of  whose  suf- 
ferings is  a  very  long  one.  Soon  after  marriage  she  began  to  be  troubled 
with  haemorrhoids;  constipation  was  always  present.  For  years  she  had 
suffered  from  chronic  metritis  and  endometritis ;  the  menses  were  very 
profuse,  lasted  eight  days,  and  were  accompanied  by  many  disturbances. 
Temporaiy  relief  was  obtained  by  douches,  silz-baths,  local  applications 
to  the  cervical  canal,  and  evacuants.  To  obtain  better  results  she  was  sent 
to  Elster ;  here  the  severe  heemorrhages  lessened,  yet  now  there  were  very 
frequent  disturbances  of  digestion  combined  with  pains  in  the  lumbar, 
inguinal,  and  imibilical  regions.  In  this  year  she  was  sent  to  Kissingen, 
on  account  of  the  incessant  complaints  produced  by  variously  located 
symptoms  due  to  stagnation  of  the  portal  circulation.  Here,  for  the 
first  time,  there  were  also  pains  and  stitches  in  the  breast,  which  usually 
appeared  after  midnight,  and  in  fact  began  only  at  night,  verj  suddenly, 
and  with  great  severity ;  after  lasting  for  hours  they  ceased,  with  marked 
eructation.  Sometimes  these  symptoms  appeared  on  several  consecutive 
nights  ;  at  other  times  the  patient  might  be  free  for  a  number  of  nights. 

''  The  patient  appeared  to  be  easily  excitable,  and,  although  emaciated, 
was  very  well  preserved  for  her  years ;  on  the  back  of  the  left  hand  and 
forearm  there  was  an  absolutely  anaesthetic  zone;  patellar  reflexes  absent; 
the  abdominal  parietes  were  very  sensitive,  even  to  delicate  i^alxjation ;  on 


412  DISEASES   OF  THE   STOMACH. 

the  other  hand,  faradic  brushing  was  scarcely  felt  here,  although  it  was 
painful  on  the  face,  arms,  and  legs.  Undoubtedly  this  was  a  hysterical 
condition  accompanying  a  reflex  dyspepsia,  proceeding  from  the  uterus, 
the  symptoms  of  the  latter  being  especially  prominent." 

The  alternation  with  neuralgias  or  neuroses  in  other  organs  is 
characteristic  of  hysterical  gastralgias.  Oser  reports  a  typical  case 
of  this  kind  in  which  hysterical  aphonia  alternated  with  attacks 
of  gastralgia  ;  this  case  suggests  very  strongly  that  the  nucleus  of 
the  vagus  was  involved.  I  have  had  under  my  observation  at  the 
Siechenanstalt,  for  almost  eighteen  months,  a  case  in  which,  to- 
gether with  persistent  constipation — the  bowels  are  never  s23ontane- 
ously  evacuated — peculiar  sensations  are  experienced  in  the  abdo- 
men, so  that  the  patient  thinks  that  a  frog  is  in  liis  stomach;  at 
other  times  he  imagines  he  has  swallowed  a  needle,  or  that  he  has  a 
tumor ;  at  times  he  also  has  attacks  of  hysterical  hoarseness  and 
aphonia.     Occasionally  he  also  has  attacks  of  true  gastralgia. 

Recently  I  had  the  opportunity  of  seeing  a  case  of  hysterical 
gastralgia,  which  was  bo  characteristic  that  it  deserves  mention  here, 
especially  as  the  treatment  renders  it  remarkable : 

On  April  1,  1888,  I  was  summoned  to  a  distant  suburb  for  a  consulta- 
tion. When  I  arrived  there  the  family  physician  was  not  present,  because^ 
as  I  was  told,  he  said  that  "  nothing  could  b*e  done  for  the  case."  I  found 
a  small,  delicate  woman  of  thirty  years,  very  much  retarded  in  her  growth ; 
she  was  living  with  her  mother  in  great  poverty,  and  had  been  in  bed  for 
eight  months  because  she  claimed  to  be  too  weak  to  walk.  What  little 
nourishment  she  took  was  liquid  ;  nevertheless,  she  was  tortured  with 
such  severe  paroxysms  of  gastralgia  that,  as  her  mother  stated,  she  scraped 
the  chalk  off  of  the  walls  and  disturbed  the  house  by  her  screaming.  In 
her  childhood  she  was  said  to  have  had  chorea.  On  physical  examina- 
tion there  was  pain  on  pressure  over  the  ovaries  and  in  the  infrasternal 
depression;  no  anaesthetic  areas,  patellar  reflexes  present,  tongue  clean, 
no  fcetor;  at  no  times  vomiting,  stools  very  constipated,  and  like  scybalae. 
The  diagnosis  of  hystei-ia  was  beyond  doubt.  To  show  the  patient  that 
she  could  walk  I  took  her  out  of  the  bed  and,  supporting  her  under  the 
arms,  I  dragged  her  about  the  room.  As  I  had  thus  convinced  myself 
that  there  were  no  organic  paralyses,  I  ordered  her  to  visit  me  the  next 
morning.  During  my  office-hours  I  was  disturbed  by  a  loud  noise;  it  was 
the  patient,  who  had  come  to  my  house  in  a  cab  after  a  ride  of  about  forty- 
five  minutes,  had  been  carried  up-stairs  by  the  coachman,  and  could  go 
about  the  room  when  supported  by  two  persons.  I  washed  out  the  stom- 
ach to  examine  its  chemical  functions,  to  reduce  the  hypersensitiveness, 
and  also  to  produce  a  moral  effect ;  while  introducing  the  tube  she  became 
very  cyanotic.     No  free  hydrochloric  acid  was  found  in  the  wash-water. 


HYSTERICAL  GASTRALGIA.  413 

I  prescribed  hydrochloric  acicl,  tincture  of  belladonna,  and  cocaine.  Six 
days  later  she  came  again  ;  but  this  time  she  was  alone,  had  walked  up 
the  stairs  very  slowly  and  with  great  exertion,  yet  without  any  help;  but 
after  that  she  had  a  typical  attack  of  hysterical  barking  cough.  The 
stomach  was  again  washed  out ;  no  free  acid,  and  a  little  peptone  was 
found.  Three  days  later  she  came  up-stairs  alone.  The  cough  had  disap- 
peared ;  had  occasional  but  only  slight  pains.  Began  to  have  appetite. 
The  stomach  was  washed  out  twice  more  at  several  days'  intervals.  On 
May  31st  I  recorded  that  speech  was  good ;  walked  without  aid,  simply  by 
holding  her  hand  lightly ;  complained  still  of  nausea,  pain  in  abdomen 
after  eating  and  walking,  and  heaviness  in  the  legs.  The  stomach  was 
found  empty  two  hours  and  a  half  after  the  test-breakfast.  Arsenic  and 
iron  were  ordered,  and  she  was  sent  to  the  country.  In  the  fall  the 
mother  reported  that  with  the  exception  of  trivial  ailments  she  had  kept 
well. 

I  do  not  consider  this  case  at  all  extraordinary.  Similar  cases 
occur  every  day,  although  possibly  the  cure  is  not  so  remarkable. 
There  was  one  coincidence,  however,  which  lent  a  peculiar  interest 
to  the  case,  that  at  my  lecture  one  of  the  audience  to  whom  the  case 
was  presented  had  formerly  treated  the  patient  for  a  long  time  with- 
out any  success. 

It  is  superfluous  to  enter  into  further  details  on  this  subject,  as 
such  cases  occur  frequently  in  practice.  The  gastralgias  constitute 
only  one  link  in  the  chain  of  tlie  manifold  group  of  symptoms ;  the 
only  point  is,  not  to  be  deceived  about  the  true  nature  of  the  at- 
tacks, and  to  recognize  the  hysterical  basis.  This  is  usually  easy  in 
most  cases,  but  it  may  be  very  difficult,  especially  when  the  hysteria 
is  manifested  by  only  one  symptom — for  example,  gastralgic  attacks 
in  old  women,  or  even  in  men.  To  exhaust  all  these  possible  forms 
would  take  me  far  beyond  my  province. 

Finally,  gastralgias  may  also  occur  iii  j^sycJioses,  and,  what  is 
especially  important,  may  be  among  the  prodromal  symptoms. 

For  a  year  and  a  half  I  treated  a  young  engineer  for  gastralgia  associ- 
ated with  neurasthenia.  He  finally  became  melancholic  and  committed 
suicide.  Psychoses  had  already  occurred  in  the  family,  and  one  brother 
had  died  in  an  insane  asylum. 


LECTUEE  XL 

THE    NEUROSES    OF   THE    STOMACH    (cONTINUED), 

I  CONSIDER  hyperacidity  and  hypersecretion  of  the  gastric  juice  to 
be  sensory  neuroses  of  the  secretory  function.  Keichmann  deserves 
the  credit  of  having  been  the  first  to  thoroughly  study  this  subject 
with  our  modern  methods ;  yet  it  is  an  error  to  suppose  that  tliese 
conditions  were  unknown  formerly.  On  the  contrary,  they  were 
described  almost  fifty  years  ago  by  Pemberton,  Copland,  Todd, 
Budd,  Trousseau,  and  among  the  Germans  by  Hiibner ;  *  but  later, 
as  these  descrijjtions  were  based  upon  speculation  rather  than  u])on 
direct  observation,  they  passed  into  oblivion.  Recently  this  subject 
has  been  especially  investigated  by  the  above  [Reichmann],  Jawor- 
ski,  von  den  Yelden,  Riegel,  Saly,  von  Noorden,  and  Honigmann. . 

Hyperacidity  is  an  increase  above  the  normal  of  the  amount  of 
hydrochloric  acid  secreted ;  it  is  due  to  the  stimulation  of  the  in- 
gesta,  the  acidity  of  which  is  heightened  after  being  incorporated 
therewith.  I^aturally,  it  is  diflicult  to  determine  where  the  normal 
acidity  ceases  and  the  abnormal  hyperacidity  begins,  as  a  sharp  line 

*  As  early  as  1820,  Pemberton  (Treatise  of  the  Various  Diseases  of  the  Abdomi- 
nal Viscercx)  speaks  of  "  a  morbidly  increased  secretion  from  the  stomach,  analo- 
gous to  a  diabetic  secretion  of  urine  by  the  kidneys"  ;  also  Copland  :  "  Or  in  other 
words,  that  pyrosis  is  produced  by  the  continuance  of  the  secretion  of  the  gastric 
juices  after  the  food  taken  into  the  stomach  has  passed  into  the  duodenum."  Budd 
also  says  that  pains,  etc.,  may  arise  "from  the  presence  of  free  acid  in  the  empty 
stomach."  Trousseau  (Des  Dyspepsies,  L'Union  med.,  1857,  p.  306) :  "Le  neuralgie 
de  I'estomac  augmente  les  secretions  acides  a  ee  point  qu'elles  se  ferront  non 
plus  comme  d'haltitude  au  moment  de  la  digestion  mais  encore  en  dehors  de  ces 
moments."  In  Hiibner  (Die  gastrischen  Krankheiten  monographisch  dargestcllt. 
Leipzig,  1844.  S.  209)  we  find  the  following :  "  If  the  morbidly  altered  secretion  of 
the  gastric  juice  ...  is  the  cause  of  the  acid,  then  the  patient  suffers  uninterruptedly 
from  it ;  he  may  eat  what  he  will,  the  symptoms  become  more  marked,  and,  as  the 
cause  persists,  it  becomes  more  obstinate  than  in  the  formation  of  acid  by  fermen- 
tation." 

(414) 


HYPERACIDITY  AND   nYPERSEORETIOK  41 5 

like  the  zero-point  in  a  tliermometer  can  not  be  drawn ;  on  the  con- 
trary, there  must  always  be  an  intermediate  stage  in  which'  the 
quantity  of  the  secretion  depends  on  individual  circumstances ;  here 
we  remain  in  doubt  whether  this  should  be  called  hyperacidity  or  not. 
However,  from  the  average  of  a  very  large  number  of  examinations 
after  the  test-breakfast  I  consider  that  hyperacidity  begins  when 
the  amount  of  acid  is  between  60  and  YO  per  cent. 

I  have  already  spoken  of  the  relation  of  hyperacidity  to  gastric 
ulcer ;  but  it  is  beyond  doubt  that  this  condition  may  exist  as  a  pri- 
mary neurosis  independently  of  any  organic  lesions.  Von  Noorden 
has  observed  it  in  melancholia,*  Jolly  claims  that  there  is  an  in- 
creased secretion  of  gastric  juice  in  hysteria,  and  Jaworskif  has 
frequently  found  it  among  the  Jews  of  Galicia,  who  are  es23ecially 
predisposed  to  nervous  disturbances.  It  may  also  occur  as  a  reflex 
symptom  of  gall-stones  and  renal  calculi ;  and  also  where  all  of 
these  factors  are  absent  the  neurotic  basis  of  the  disorder  may  be 
recognized  by  the  w^ant  of  success  in  treatment  directed  toward  the 
cure  of  a  supposed  gastric  ulcer. 

In  the  summer  of  1887  I  treated  a  girl  of  nineteen  years  for  nearly 
three  months  for  a  supposed  gastric  ulcer,  because  she  had  periodical  gas- 
tralgia,  and  a  hyperacidity  of  88  per  cent.  The  absolute  failure  of  the 
treatment,  and  the  constant  recurrence  of  the  attacks,  in  spite  of  the  im- 
provement in  the  general  condition  and  the  increase  in  weight,  indicated 
a  purely  neurotic  basis  of  the  disorder,  although  other  symptoms  of  neur- 
asthenia and  hysteria  were  lacking. 

Hypersecretion,  or  better,  parasecretioii  (the  Ifagensaftjlass  of 
Reichmann),  may  occur  in  two  forms,  the  periodical  and  the  con- 
tinuous. The  acidity  is  not  increased,  as  a  rule,  in  the  former,  but 
it  is  in  the  latter.  Periodically,  it  usually  occurs  after  eating,  rarely 
while  fasting,  yet  it  does  not  seem  to  have  a  direct  connection  with 
the  introduction  of  food.  Wilkens;}:  reports  a  typical  case  of  this 
kind. 


*  Sitzungsbericht  tier  medicin.  Gesellschaft  zu  Giessen.  Abstract  in  Berlin, 
klin.  Wochensehr.,  1887,  No.  18. 

f  W.  Jaworski.  Zusainmenhaag  zwisehen  subjectiven  Magensymptomen  und 
objectiven  Befunden  bei  Magenfunetionsstorungen.  "Wiener  med.  Wochensehr., 
1886,  Nos.  49-52. 

X  S.  A.  Wilkens.  A  Case  of  Hypersecretion  in  Intermittent  Attacks.  Lancet, 
August  27,  1887. 


416  DISEASES  OP  THE  STOMACH.    . 

A  musician,  thirty-six  years  old,  who  led  an  emotional  life,  for  the  pre- 
ceding three  years  and  a  half  had  attacks  of  vomiting  and  pain  in  the 
stomach;  during  the  paroxysms  he  could  neither  eat  nor  drink,  and  had 
to  go  to  bed.  Similar  attacks,  which  lasted  twenty-seven  to  thirty -five 
hours,  recurred  at  intervals  of  ten  to  twelve  days.  He  lost  in  weight  from 
2  to  3i  kilogrammes  m  to  7|  pounds].  Intense  hunger  between  the  attacks. 
The  gastric  juice  vomited  was  about  two  pounds  and  a  half,  and  every 
time  had  0"12  per  cent  HCl.     Diagnosis,  affection  of  the  secretory  nerves. 

All  writers  agree  that  tlie  condition  is  a  functional  disturbance 
of  the  nerves  of  the  stomach,  which  may  occur  alone  or  as  part  of 
other  neuroses.  In  chronic  hypersecretion  {continuirliche  Magensaft- 
fluss)  there  is  a  continuous  secretion  of  gastric  juice  which  is  usu- 
ally hyperacid,*  so  that  even  while  fasting  the  stomach  may  con- 
tain larger  or  smaller  quantities,  varying  between  100  and  1,000  c.  c. 
[f  §  iijss.  to  Oij],  or  more,  of  a  fluid  very  much  resembling  ordinary 
gastric  juice,  but  without  any  remnants  of  food,  and  frequently 
tinged  grass-green  or  bluish-green  by  the  admixture  of  bile.f  The 
degree  of  acidity  is  bigb,  but  the  amount  of  free  hydrochloric  acid 
which  can  affect  the  color  reagents  is  very  variable,  as  has  been 
shown  by  Jaworski ;  X  since  in  cases  with  the  same  degree  of  acid- 
ity, in  some  there  was  much  free  acid  and  a  feeble  biuret  reaction^ 
in  others,  little  free  acid,  in  spite  of  the  absence  of  organic  acids 
and  a  marked  biuret  action ;  finally,  in  rare  cases  having  a  certain 
degree  of  acidity  no  reactions  can  be  obtained,  although  one  would 
expect  a  positive  result  with  all  the  color-tests.  Jaworski  attributes 
this  to  the  larger  or  smaller  admixture  of  desquamated  tissue-ele- 
ments of  the  mucous  membrane  or  emigrated  white  blood-cells,  or 
even  blood-serum,  which  by  forming  peptone  or  acid  combinations 
may  combine  with  part  or  all  of  the  free  hydrochloric  acid  in  the 
sense  which  I  have  already  explained  (page  27)  for  the  albuminoids 
in  general,  and  which  has  since  been  demonstrated  by  von  Pfungen. 

On  taking  food  it  is  found  that  the  digestion  of  starches  is  de- 
layed, but  is  very  prompt  in  albuminoids,  so  that  after  a  meal  con- 


*  Jaworski,  loc.  cit.—m  121  cases  of  hypersecretion,  hyperacidity  was  found  at 
the  same  time  in  115  of  them. 

f  Jaworski,  loc.  cif. — 77  times  in  222  cases, 

t  Jaworski.  Ueber  die  Versehiedenheit  in  der  Beschaffenheit  des  ntichternen 
Magensaftes  bei  Magensaftfiuss  (Gastrorrhoea  acida).  Verhandlungen  des  Con- 
gre?ses  f.  innere  Med.     Wiesbaden,  1888,  S.  280. 


HYPERACIDITY  AND   HYPERSECRETION.  41Y 

sisting  of  meat  and  amylaceous  substances  one  may  find  abundant 
remnants  of  undigested  starches,  but  no  ,trace  of  meat  (Riegel). 
While  fastiiig  the  fluid  in  the  stomach  no  longer  contains  the  usual 
varieties  of  epithelium,  but  instead  many  nuclei  with  sharp  con- 
tours, which  Trinkler  *  (who  first  called  attention  to  them  in  ani- 
mals), Jaworski,  and  myself  consider  to  be  remains  of  undigested 
cells.  According  to  Jaworski,  this  condition  of  chronic  hypersecre- 
tion must  be  almost  the  rule,  since  among  159  cases  he  found  115 
with  hyperacid  and  continuous  secretion.  Riegel  does  not  go  to 
such  extremes,  yet  he  claims  that  it  occurs  in  about  half  of  all  the 
cases  of  stomach  disorders. 

This  does  not  agree  with  my  experience.  Strictly  speaking,  I 
am  not  competent  to  give  an  opinion  on  this  question,  because  I 
have  only  examined  while  fasting  those  patients  whose  complaints — 
pains,  heart-burn,  eructation,  etc.,  occurring  during  the  night  or  in 
the  morning  before  eating — afforded  me  an  opportunity  of  exploring 
the  empty  stomach ;  under  these  circumstances,  I  have  not  often 
found  hypersecretion.  Even  if  I  follow  Riegel's  example,  and  in- 
clude the  cases  of  dilatation,  my  experience  extends  only  over  45 
such  cases  among  about  1,200  patients  whom  I  have  examined  and 
kept  records  of  during  the  past  few  years.  I  found,  as  other  writers 
have,  that  men  predominate — 30  men  and  15  women.  We  must 
leave  it  a  mooted  question  whether,  as  claimed  by  von  den  Yelden, 
hypersecretion  is  only  a  lengthened  reaction  toward  the  stimulation 
of  the  food,  or  whether  it  is  continuous,  as  asserted  by  Eeichmann, 
Riegel,  myself,  and  others. 

The  irritation  of  the  mucous  membrane  by  the  acid  fluid  causes 
hypersesthesia,  the  results  of  which  are  tenderness  or  pain  in  the 
epigastrium,  acid  eructation,  heart-burn,  vomiting  of  sour  masses, 
gastralgias,  and  similar  digestive  disturbances  which  constitute  the 
symptoms  of  a  chronic  inflammatory  condition.  Under  certain  con- 
ditions, as  observed  by  Talma,f  the  stomachs  of  neurasthenics  may 
react  abnormally  toward  acids.     But  the  tongue  is  usually  clean, 

*  Trinkler.  Ueber  den  Bau  der  Magenschleimhaut.  M.  Schultze's  Archiv,  Bd. 
xxiv,  S.  195. 

t  S.  Talma.  Zur  Behandlung  von  Magenkrankheiten.  Zeitschrift  ftir  klin. 
Med.,  Bd.  8,  S.  407. 


418  DISEASES  OF  THE  STOMACH. 

and  the  appetite  is  increased  rather  than  diminished.  Excessive 
thirst  was  common  in  Jaworski's  cases,  and  (what  is  by  no  means 
wonderful)  was  said  to  have  been  relieved  by  drinking  water  and 
diluting  the  contents  of  the  stomach.  Among  the  results  of  this 
condition  we  must  consider  atony  of  the  muscular  coat  of  the  stom- 
ach, and  the  gastrectasis  due  to  it ;  where  the  condition  has  lasted 
a  long  time,  this  is  so  common  that  twenty-nine  more  or  less  well- 
marked  dilatations  of  the  stomach  were  found  in  thirty  cases  at 
Prof.  Riegel's  clinic*  But  by  this  time  the  neurosis  has  been  con- 
verted into  an  organic  lesion,  and  such  conditions  must,  therefore, 
1)0  considered  among  the  cases  of  gastrectasis,  and  not  among  the 
gastric  neuroses. 

The  exact  diagnosis  of  this  condition  can  only  be  made  by  exam- 
ining the  stomach-contents,  and  so  far  as  concerns  chronic  hyper- 
secretion this  examination  must  be  made  while  fasting.  A  clew  to 
this  state  is  afforded  by  the  fact  that  the  symptoms  are  temporarily 
ameliorated  by  eating  proteids ;  this  differentiates  it  from  the  dis- 
turbances caused  by  the  pyrosis  and  gastralgia  due  to  acid  fermenta- 
tion. The  alkalies  give  temporary  relief  in  both  conditions  of  nerv- 
ous hyperacidity  and  acid  fermentation  ;  yet  the  difference  is  this, 
that  for  the  former  we  have  no  other  direct  remedy  excepting  this 
purely  symptomatic  one ;  but  fermentation  may  be  controlled  and 
prevented  by  specific  measures. 

Among  these  neuroses  I  also  classify  the  condition  called  Gas- 
troxynsis  [Yao-TT^p,  stomach,  o^y?,  acid]  by  Kossbach,  which  differs 
from  migraine  only  in  the  fact  that  it  does  not  occur  spontaneously 
as  frequently  as  the  latter,  but  as  the  result  of  definite  causes,  men- 
tal over-exertion,  or  profound  emotional  disturbances,  and  that  the 
vomited  masses  are  very  acid,  containing  as  much  as  3'4  to  4  per 
thousand.  However,  the  latter  is  common  to  both  the  condition 
and  typical  migraine,  since  I  have  repeatedly  obtained  equally  high 
results  in  the  latter.  Jiirgensen  f  has  also  observed  very  similar 
states. 

ITervoTis  Belching,  Enictatio. — It  is  only  in  hysterical  persons  that 

*  Honigniann,  loc.  cit. 

f  Jiirgensen.     Ueber  Abscheidung  neuer  Formen  nervoser  Magenkrankheiten. 
Deutsch.  Archiv  fiir  klin.  Med.,  Bd.  43,  S.  9-30. 


NERVOUS  BELCHlNa.  419 

I  have  seen  this  occur  alone,  for  in  neurasthenics  it  is  always  asso- 
ciated with  other  sensations,  especially  oppression  and  tension  in  the 
epigastrium.  I  agree  with  Weissgerber,*  who  has  published  a  very 
long  paper  on  eructation,  that  in  the  former  [hysteria]  there  is  a 
heightened  contractility  of  the  stomach,  together  with  an  increased 
tone  of  the  pylorus,  provided  the  other  manifestations  of  hysteria 
are  also  considered  among  the  jDrocesses  of  irritation.  Since  the 
sphincter  at  the  pylorus  is  stronger  than  that  at  the  cardia,  it  w^ill 
contract  more  powerfully  even  if  both  are  equally  stimulated  ;  hence, 
when  the  distention  of  the  stomach  is  so  great  that  it  must  expel 
some  of  its  gas,  this  can  escape  more  readily  upward  than  down- 
ward. For  it  can  not  be  doubted  that  eructation  is  an  active  and 
not  a  passive  process.  It  may  be  possible,  as  claimed  by  Stiller  and 
Rosenthal,  that  a  relaxation  of  the  cardia  may  facilitate  the  exit  of 
the  gases  from  the  stomach,  and  that  hence,  according  to  circum- 
stances, eructation  may  be  due  either  to  an  increase  or  a  paralysis 
of  the  muscular  action  of  the  stomach.  However,  in  many  cases, 
belching  certainly  has  nothing  to  do  with  relaxation  of  the  cardia, 
as  is  shown  by  the  numerous  patients  who  try  in  vain  to  empty  their 
stomachs  of  the  accumulated  gas. 

There  is  another  kind  of  belching  which  is  entirely  independent 
of  the  stomach,  in  which  the  gas  is  raised  only  from  the  cesophagus 
by  contracting  the  muscles  of  the  neck,  just  as  Bristowe  f  has  as- 
sumed in  hysterical  vomiting.  This  form  escaped  Weissgerber's 
notice  entirely,  I  myself  can  belch  voluntarily,  and  I  have  con- 
vinced myself  by  means  of  the  deglutition-murmur  (SGhlucJcge- 
rdusch)  that  the  air  which  is  compressed  in  the  oesophagus  does  not 
enter  the  stomach  unless  additional  true  movements  of  deglutition 
are  executed,  We  may  therefore  accept  the  fact  that  it  is  possible 
to  belch  from  the  oesophagus  alone,  and  this  may  explain  many 
cases  of  hysterical  eructation  in  which  the  stomach  is  not  distended. 

Belching  may  become  a  very  annoying  symptom,  since  it  is  never 
noiseless  but  is  usually  quite  loud.    In  one  attack,  of  an  hour's  dura- 

*  Weissgerber.  Ueber  den  Mechanismus  der  Ructus  und  Bemerkungen  iiber 
den  Lufteintritt  in  den  Magen  Neugeborener,    Berl.  klin.  Wochenschr.,  1878,  No.  35. 

f  Bristowe.  Clinical  Remarks  on  the  Functional  Vomiting  of  Hysteria,  Prac- 
titioner, 1883,  p.  161. 

27 


420  DISEASES  OF  THE  STOMACH. 

tion,  Cartellieri  *  was  able  to  count  it  twenty-five  liundred  times ! 
The  gas  is  always  odorless  and  tasteless,  and  tlius  differs  in  tliis  re- 
spect from  that  raised  in  true  dyspepsia,  fermentative  processes,  etc. 
It  therefore  must  consist  of  atmospheric  air  which,  in  the  opinion  of 
most  authors,  must  have  been  swallowed,  but  which  may  also  possi- 
bly come  up  from  the  intestines  ;  in  many  cases  it  is  certainly  raised 
only  from  the  oesophagus.  Cartellieri  says  his  patient  had  no  time 
to  swallow  air  during  the  attack  ;  in  such  cases  the  question  then 
arises.  Is  air  really  ex|)elled,  or  is  it  a  manifestation  in  which  this  is 
simulated  ?  So  far  as  I  know,  this  subject  has  never  been  investi- 
gated. 

Pyrosis  denotes  the  raising  of  sour  masses  from  the  stomach, 
an  act  which  is  well  known  under  the  name  of  heart-burn.  In  the 
nervous  forms  of  this  symptom  at  least,  the  stomach-contents  are 
not  necessarily  hyperacid  ;  on  the  other  hand,  severe  acrid  and 
•  burning  sensations  may  be  produced  by  the  regurgitation  of  even 
normal  stomach-contents  or  gastric  juice.  Here,  also,  one  may  be  in 
doubt  whether  the  cause  resides  in  a  heightened  contraction  of  the 
muscular  coat  of  the  stomach,  or  in  a  paralysis  of  the  cardiac  sphinc- 
ter. I  have  been  led  to  classify  this  phenomenon  among  the  motor 
conditions  of  irritation,  because  I  have  in  vain  searched  for  the  sign 
of  a  marked  relaxation  of  the  cardia,  the  occurrence  of  the  first  deg- 
lutition-murmur.    [See  foot-note,  p.  61.] 

This  brings  us  to  the  consideration  of  a  very  annoying  condition 
called  Pneumatosis,  tympanites  {Trommelsucht).  Here  the  stomach 
is  filled  with  sas,  and  mav  become  so  distended  that  it  causes  not 
alone  the  unpleasant  sensation  of  marked  tension,  but  even  severe 
nervous  symptoms,  by  pushing  the  dia]3hragm  upward  and  pressing 
on  the  heart.  The  patients  are  seized  with  typical  attacks  of  asthma 
— the  asthma  dyspepticum  of  Henoch — in  which  at  first  there  is 
only  the  annoying  feeling  of  being  compelled  to  take  deep  inspira- 
tions after  short  periods  of  normal  breathing ;  at  the  beginning  this 
suffices,  but  later  it  develops  into  an  incessant  dyspnoea.  ]^ow  there 
is  also  palpitation  of  the  heart,  pulsation  of  the  peripheral  arteries, 

*  P.  Cartellieri.     Bine  seltene  vorkommende  Magenneurose.    Wiener  allgemeine 
med.  Zeitung,  1885,  S.  3. 


NERVOUS  VOMITING.  421 

fullness  of  the  head,  and  even  tlie  feeling  of  impending  death,  or 
complete  unconscionsness — in  short,  such  is  the  condition  that  I 
have  been  repeatedly  told  by  many  sufferers  that  they  were  almost 
driven  to  suicide.  Relief  can  only  be  afforded  by  bringing  up  some 
of  the  gas,  and  then  the  attack  rapidly  subsides.  This  condition  is 
probably  caused  by  the  air  which  has  been  swallowed,  together  with 
a  spasm  of  the  sphincters  of  the  stomach.  The  chemical  processes 
were  normal  in  one  case  which  I  examined,  yet  the  same  state  may 
be  produced  in  dyspeptics  by  the  gas  generated  in  fermentation. 

The  attacks  may  be  relieved  instantly  by  introducing  the  stom- 
ach-tube and  allowing  the  gas  to  escape.  But  it  seems  that  it  is  very 
difficult  to  cure  the  disease  itself  where  it  is  nervous  in  character. 
In  one  case  of  pneumatosis  I  had  no  success  with — 

^  Cocain.  hydrochloratis 1"0  [gr.  xv] 

Aq.  amygdal.  amarse lO'O  [f  3  ijss.] 

M.     Sig. :  Ten  drops  every  two  hours. 

Large  doses  of  bromide  of  potassium  had  also  been  given,  but 
without  producing  any  effect.  In  another  case  hypodermic  injec- 
tions of  morphine  into  the  epigastrium  gave  immediate  relief;  a 
third  case  was  cured  by  change  of  climate.  The  patient  was  a  Bra- 
zilian, who,  while  at  home,  had  suffered  very  severely  from  pneuma- 
tosis, but  here  [Germany]  he  was  entirely  free  from  it. 

Nervous  Vomiting. — This  includes  those  forms  of  vomiting  which 
are  caused  neither  by  anatomical  lesions  of  the  stomach  nor  by 
quantitative  or  qualitative  changes  in  the  food.  It  is  pre-eminently 
reflex,  and  may  be  caused  either  directly  by  the  vomiting-center  or 
indirectly  from  other  points  in  the  central  nervous  system,  or  from 
other  organs.  As  far  as  we  know,  the  causes  of  this  condition  may 
include  palpable  changes  in  the  brain  and  spinal  cord,  kidneys, 
uterus,  liver,  and  certain  organs  of  sense.  These  forms  of  nervous 
vomiting  may  be  classed  among  the  reflex  neuroses. 

I  have  had  the  opportunity  of  observing  two  such  cases  of  nerv- 
ous vomiting  in  close  succession  ;  during  their  course  they  seemed 
to  be  very  much  alike,  yet  the  nature  of  the  primaiy  affection  Caused 
them  to  terminate  very  differently. 

The  first  case  was  a  married  lady,  thirty -six  years  old,  who  had  been  suf- 
fering for  three  weeks  with  uncontrollable  vomiting  and  a  continuous  flow 


422  DISEASES  OF   THE  STOMACH. 

of  saliva,  together  with  strong  foetor  from  the  mouth.  This  condition  had 
come  on  after  an  attack  of  catarrhal  jaundice,  traces  of  which  were  just 
recognizable  in  a  slight  discoloration  of  the  scl  erotics  at  the  time  I  first 
saw  the  patient.  She  had  emaciated  very  little  considering  that  she  had 
taken  scarcely  any  nourishment  during  this  period,  for  she  vomited  every- 
thing immediately  after  eating.  On  examination,  nothing  could  be  found 
anywhere,  not  even  in  the  liver.  The  passages  were  loose  and  bright 
yellow.  Only  temporary  relief  was  obtained  by  the  hypodermic  use  of 
morphine  with  atropine,  washing  out  the  stomach  with  chloroform  water, 
and  chloroform  internally.  Finally,  the  attacks  were  controlled  by  with- 
holding all  food  and  drink  by  the  mouth,  and  using  nutritive  enemata 
for  several  days.  But  the  salivation  kept  up  some  weeks  longer,  when  it 
ceased  entirely.  The  condition  here  was  probably  a  reflex  irritation  from 
a  gall-stone;  hysteria  was  excluded  because  the  patient  was  otherwise 
healthy  and  the  mother  of  several  grown-Tip  children.  I  must  not  con- 
ceal the  fact  that  for  a  long  time  the  patient  caused  me  a  good  deal  of 
anxiety  on  account  of  the  absence  of  definite  points  on  which  to  base  a 
diagnosis. 

The  second  case  was  a  lady  in  the  fifties,  living  outside  of  Berlin ;  un- 
fortunately, I  had  the  opportunity  of  seeing  her  only  once.  In  the  early 
part  of  1888  she  experienced  profound  emotional  disturbances ;  since  the 
following  summer  she  had  suffered  from  mild  gastric  troubles  which 
lasted,  with  variable  intensity,  till  November.  After  that  every  meal  was 
regularly  followed  by  vomiting,  which  had  continued  with  few  intermis- 
sions till  the  beginning  of  January,  when  I  saw  the  patient.  The  woman, 
who  had  formerly  been  strong,  was  now  very  much  run  down;  she  had 
frequent  attacks  iit  unconsciousness,  and  complained  of  great  weakness?, 
especially  in  the  legs.  Sleep  was  good.  The  urine  had  been  repeatedly 
examined,  but  albumen  and  sugar  were  not  found. 

I  found  a  bedridden  patient  who  was  still  quite  well  nourished  in  spite 
of  the  emaciation  she  complained  of;  she  could  move  quite  readily  in  the 
bed ;  she  spoke  with  deliberation ;  in  short,  she  seemed  less  afl'ected  than 
was  to  be  expected  from  her  history.  On  examination  I  could  find  noth- 
ing but  a  struma,  and  tachycardia  up  to  one  hundred  and  twenty  beats  per 
minute.  There  was  no  tumor  nor  any  tenderness  in  the  abdomen.  Pa- 
tellar reflexes  normal ;  pupils  reacted  well ;  no  limitation  of  the  field  of 
vision,  and  no  complaints  about  sight.  Sensation  everywhere  normal. 
Heart  and  lungs  negative. 

In  my  presence  the  patient  ate  two  pieces  of  toast  and  drank  a  glass  cf 
water  without  vomiting.  The  tube  was  easily  introduced  and  the  stomach- 
contents  expressed  twenty-five  minutes  after.  No  hydrochloric  acid 
found ;  the  fragments  of  toast  were  scarcely  at  all  digested.  This  result 
left  the  diagnosis  in  doubt  between  a  severe  neurosis  and  an  occult  car- 
cinoma ;  yet  the  absence  of  true  cancerous  cachexia  favored  the  former. 
The  rapidity  of  the  pulse  was  attributed  to  the  struma;  tabes  accompa- 
nied by  gastric  crises  was  excluded  on  account  of  the  absence  of  its  specific 
symptoms. 

The  condition  seemed  to  improve  at  first  by  using  nutritive  enemata 
and  restricting  feeding  by  the  mouth  as  much  as  possible;  small  doses  of 


NERVOUS  VOMITING.  423 

digitalis  and  atropine  were  also  given.  But  she  soon  relapsed  into  the 
old  condition;  she  gradually  grew  weaker,  till  one  day  she  was  seized  with 
epileiJtic  convulsions  and  died  several  days  later.  An  autopsy  was  not 
allowed,  yet  the  whole  clinical  picture  led  me  to  diagnosticate  an  affection 
of  the  medulla  oblongata,  probably  a  tumor,  involving  the  roots  of  the 
vagus,  thus  causing  the  persistent  vomiting  and  the  rapid  pulse.  At  all 
events,  this  presupposes  such  a  situation  of  the  suspected  tumor  that  the 
nucleus  of  the  fibers  of  the  vagus  distributed  to  the  heart  was  paralyzed 
or  destroyed,  while  those  fibers  going  to  the  stomach  were  kept  in  a  con- 
dition of  chronic  irritation.  The  soundness  of  this  supposition  remains 
in  doubt,  although  it  is  by  no  means  without  a  j)arallel  (Rosenthal;. 

Botli  of  these  cases  are  typical  examples  of  severe  vomiting 
caused  by  nervous  irritation,  and  at  the  same  time  they  show  how 
difficult  (sometimes  even  impossible)  it  is  to  make  a  diagnosis  at  a 
given  time  during  life. 

For  a  certain  group  of  cases  we  are  unable  to  find  this  proof, 
although  we  may  suspect  the  reflex  origin.  Pre-eminent  among 
these  stands  the  vomiting  of  neurasthenic  and  hysterical  patients ; 
it  is  uncommon  among  the  former,  but  occurs  frequently  in  the 
latter.  It  is  characteristic  of  this  form  of  vomiting  that  it  usually 
occurs  without  any  true  nausea,  and  that  the  retching  is  reduced  to  a 
minimum.  Hysterical  vomiting  may  occur  after  every  meal ;  some- 
times it  is  less  frequent.  Either  all  food  may  be  rejected  or  only 
certain  kinds  or  even  individual  dishes.  I  made  use  of  this  fact  in 
making  my  first  investigations  on  the  course  of  normal  digestion  in 
human  beings ;  my  subject  was  a  hysterical  girl  who  could  retain 
all  kinds  of  solid  food,  but  was  compelled  to  vomit  whenever  she 
swallowed  any  fluid.  Another  young  girl,  who  has  now  been  over 
five  years  at  the  Siechenanstalt,  regularly  vomits  nearly  all  that  she 
has  eaten  almost  immediately  after  every  meal.  The  general  nutrition 
suffers  surprisingly  little  from  this  persistent  vomiting ;  thus  the  sec- 
ond patient's  weight  has  been  almost  the  same  during  the  j)ast  four 
years;  she  has  come  down  from  40*5  to  39'5  kilogrammes  (89  to  8Y 
pounds).  In  other  cases  the  vomiting  does  seem  to  affect  the  weight. 
Thus  Tuckwell  *  reports  that  three  children  were  very  greatly  emaci- 
ated after  prolonged  vomiting  which  lasted  for  months  ;  it  was  con- 
trolled by  sitting  the  little  patients  up  as  soon  as  any  tendenc}'  to 
vomiting  occurred  (and  also,  to  be  sure,  carefully  regulating' the  diet). 

*  Tur-kwell.     On  Vomiting  of  Habit.     British  Med.  Journal,  March  22,  1873. 


424:  DISEASES  OF  THE  STOMAC^H. 

Barras  *  speaks  of  a  woman  who  suffered  from  nervous  vomiting,  but 
who  ceased  to  vomit  while  she  was  in  the  bath ;  she  was  cured  after 
her  meals  were  given  to  her  in  this  way. 

This  affection  may  pursue  an  acute  or  chronic  course ;  it  may 
begin  spontaneously  or  may  follow  some  demonstrable  cause.  One 
young  girl  was  attacked  immediately  after  the  death  of  her  father ; 
ian other  as  the  result  of  bi'eaking  off  an  engagement  of  marriage. 
As  in  other  neuroses,  the  female  sex  is  especially  liable. 

I  must  confess  that  my  experience  of  the  infrequent  occurrence 
of  vomiting  in  neurasthenics  does  not  agree  with  that  of  Rosenthal, 
who  claims  to  have  seen  it  not  infrequently  in  this  class  of  patients. 
I  shall  simply  content  myself  with  giving  the  headings  of  two  of 
his  histories  : 

Observation  No.  31. — Neurasthenia,  hyperaesthesia  toward  acids  with 
consecutive  gastric  colic  and  vomiting.  Cured  by  local  remedies  (small 
pieces  of  ice,  with  two  to  three  drops  of  tincture  of  nux  vomica)  and  gen- 
eral invigorating  treatment. 

Observation  No.  32. — Neurasthenia  following  onanism,  with  frequent 
vomiting.  After  the  latter  bad  ceased  it  began  again  after  each  coitus, 
whDe  a  heavy  meal  did  not  cause  any  complaints.  Neurasthenia  and 
vomiting  cured  by  prohibiting  sexual  intercourse  at  the  beginning  of  the 
treatment,  increasing  doses  of  potassium  bromide,  with  some  pyrophosph. 
ferri  citronatric.  [Ph.  Austr.],  Neptune's  girdle,  galvanization  of  the  sym- 
pathetic, and  hydriatic  procedures. 

This  difference  in  observation  might  appear  striking ;  yet  it  may 
be  readily  explained  by  the  fact  that  two  observers  in  places  at 
some  distance  from  each  other  [Berlin  and  Yienna]  deal  with  dif- 
ferent kinds  of  patients.  Concerning  the  multiplicity  and  intensity 
of  all  neuroses  it  is  peculiar  that  they  most  frequently  attack  the 
easily  excitable  Southerners,  and  especially  the  nationalities  living 
near  the  military  border.  Hypersecretion  seems  also  to  occur  more 
frequently  there  than  in  Germany. 

Finally,  I  must  speak  of  a  form  of  nervous  vomiting  which  was 
described  by  Leyden.f  It  may  occur  as  a  primary  neurosis,  or  as  a 
secondary  spinal  affection,  or  as  a  reflex  form.  A  peculiarity  of  this 
variety  is  the  periodicity  of  the  attacks  [whence  the  name  periodical 

*  Barras.     Traite  sur  les  gastralgies  et  enteralgies.     Paris,  1827. 
t  Leyden.    Ueber  periodisches  Erbreehen  (gastrisehe  Krisen)  nebst  Bemerkungen 
iiber  nervose  Magenaffectionen.     Zeitschrift  f iir  klin.  Medicin,  1882,  Bd.  iv,  S.  605. 


PERISTALTIC  UNREST  OF  STOMACH.  425 

vomiting],  wliicli  may  last  from  a  few  hours  to  a  number  (ten)  of 
days.  They  begin  with  sudden  nausea  and  coHcky  contractions  of 
the  intestines,  but  the  abdominal  wall  is  relaxed.  At  first  the  vomit 
consists  of  food  debris  and  slimy  masses,  later  of  bile  and  streaks 
of  blood ;  the  attacks  accompanied  by  migraine  and  tearing  sensa- 
tions in  the  limbs ;  they  are  followed  by  obstinate  constipation, 
which  is  due  to  a  spasm  of  the  intestine.  The  trouble  may  last  for 
years,  but  its  origin  can  only  be  sought  in  the  directions  indicated 
above.     In  two  of  my  cases  the  autopsies  gave  negative  results. 

Stomach  colics  are  usually  included  among  the  gastralgias.  In 
fact,  they  frequently  occur  together,  since  stomach  colic  is  accom- 
panied by  severe  pains.  But,  as  indicated  by  the  name,  the  pains 
are  colicky,  and  are  due  to  a  spasmodic  contraction  of  the  viscus ; 
but  they  are  not  boring  and  shooting,  as  in  genuine  gastralgias. 
The  causal  factors  are  the  same  as  those  which  have  been  described 
under  the  gastralgias. 

Localized  spasms  may  occur  at  the  cardia  and  pylorus.  While 
introducing  the  stomach-tube  we  sometimes  experience  the  sensation 
as  if  the  instrument  were  spasmodically  gripped  at  the  cardia.  It 
would  be  difficult  to  ascertain  whether  this  is  due  to  a  contraction 
of  the  lower  segment  of  the  oesophagus  or  of  the  cardia. 

Spasm  of  the  pylorus  seems  to  be  due,  disregarding  the  irritation 
from  local  changes,  to  gastric  juice  which  is  either  too  acid  or 
which  has  been  secreted  at  improper  times.  This  is  the  only  way 
of  explaining  hyperacidity  and  hypersecretion,  as  has  been  sug- 
gested by  Boas  and  myself. 

In  distention  of  the  stomach  with  gas,  its  escape  upward  or 
downward  can  only  be  prevented  by  an  abnormally  tight  closure  of 
the  gastric  sphincters. 

Peristaltic  Unrest  of  the  Stomach  {PeristaltiscJie  Unruhe,  Tor- 
mina ventriculi  nervosa). — This  was  first  described  by  Kussmaul* 
as  being  caused  by  an  increased  peristalsis,  which  is  so  intense  and 
so  well  marked  that  it  may  readily  be  perceived  through  the  relaxed 
abdominal   parietes,  and  which  may  at  times  be  accompanied  by 


*  Kussmaul.    Volkmann's  Sammlung  klinischeVortrage,  1880,  No.  181.    [Also, 
Boas,  Deutsch.  med.  Wochenschr.,  October  17,  1889. — Tr.] 


426  DISEASES  OF  THE   STOMACH. 

gurgling  and  rumbling  loud  enough  to  be  lieard  at  a  distance.  Tliis 
affection,  bj  itself,  is  not  painful,  yet  it  may  torture  the  sufferer  to 
extremes.  "  It  is  just  as  if  the  intestines  were  twisted  around  in- 
side m J  abdomen,"  was  told  to  me  recently  by  a  female  patient, 
forty-six  years  of  age,  in  whom  the  noises  in  the  gut  were  so  marked 
that  they  were  audible  as  soon  as  she  entered  the  room.  They  are 
most  intense  after  meals,  yet  they  do  not  disappear  entirely  between 
them  ;  and,  like  other  neuroses,  they  have  the  characteristic  pecul- 
iarity that  they  sometimes  suddenly  cease  when  the  patient  becomes 
excited — for  example,  during  the  doctor's  visit — although  a  moment 
before  they  were  present  in  full  intensity.  Knssmaurs  earliest  cases 
were  persons  with  gastrectasis,  and  the  majority  of  the  cases  which 
have  since  been  observed  have  been  snch  patients. 

The  reverse  of  this  condition,  antiperistaltic  unrest  of  the  stom- 
ach, has  been  observed  by  Glax  *  as  a  pure  neurosis.  His  was  a 
typical  case ;  the  examples  which  had  previously  been  published  by 
Schiitz  and  Colin  were  not  free  from  criticism.  Glax's  case  was  a 
man,  thirty-two  years  old,  who  had  formerly  suffered  from  dys]3eptic 
disturbances  and  a  slight  dilatation  of  tlie  stomach  ;  the  writer  de- 
scribes his  condition  as  follows  : 

"  A  shallow  but  distinct  constriction  could  be  seen  passing  vertically- 
downward  over  the  stomach  from  the  right  sternal  border.  Suddenly  to 
the  left  of  this  the  fundus  ventriculi  ax^peared  hard,  and  tense,  and.  grad- 
ually expanded  to  the  size  of  a  child's  head ;  this  swelling  slowly  went 
down,  then  appeared  to  the  right  of  the  constriction,  and  then  began 
almost  immediately  to  the  left  again.  Often,  however,  the  movement 
distinctly  passed  from  the  right  back  to  the  left  in  an  antiperistaltic  di- 
rection. I  then  distended  the  stomach  with  carbonic-acid  gas,  which 
caused  the  movements  to  become  very  active." 

Errors  may  arise  from  the  not  infrequent  occurrence  of  peri- 
staltic unrest  of  the  intestines  ;  this  may  also  assume  an  antiperistaltic 
form.  That  this  may  actually  happen  is  shown  by  the  cases  of  Bri- 
quet, Jaccoud  and  Fouquet,  and  Rosenstein,  in  which  scjdjalse  and 
discolored  enemata  were  evacuated  through  the  mouth.f     In  many 

*  Glax,  loc.  cit,  p.  190. 

f  [A  case  of  habitual  defecation  by  the  mouth  has  been  recently  reported  by 
Desnos  (Wiener  med.  Presse,  1891,  No.  51,  S.  1958).  The  case  was  that  of  a  man 
who  was  found  on  the  street  in  an  epileptic  attack ;  the  saliva  which  flowed  from 
the  mouth  was  apparently  mixed  with  faecal  matter.     Upon  inquiry,  the  patient 


POLYPHAGIA.  427 

persons  stroking  the  finger-nail  rapidly  and  sliarj)ly  across  the  epi- 
gastrium will  produce  distinct  peristaltic  movements. 

II.  Conditions  of  Depression. 

Concerning  the  conditions  of  anaesthesia  of  the  stomach  we  know 
very  little,  or  rather,  it  would  be  truer  to  say,  practically  nothing. 
In  Lecture  IX  attention  was  drawn  to  this  point ;  and,  as  we  nor- 
mally have  no  perception  of  the  processes  going  on  in  and  about 
our  stomachs,  we  can  not,  therefore,  gain  any  distinct  conceptions 
of  a  pathological  lack  of  sensitiveness. 

Polyphagia,  or  acoria  [a,  without,  Kopico,  I  satiate],  the  want  of 
the  feeling  of  satiation,  is  best  regarded  as  a  result  of  ansesthesia  of 
the  stomach. 

If  in  the  discussion  on  bulimia  and  anorexia  I  have  made  it  evi- 
dent that  tliese  conditions  are  due  to  an  over-excitation  of  centers  in 
the  brain,  then  satiation  must  be  considered  an  inhibition  of  hunger, 
and  the  absence  of  this  sensation  a  negative  phenomenon — i.  e., 
either  the  liuno;er-center  is  no  longer  under  the  influence  of  the 
nervous  paths  passing  to  it,  or  the  latter  are  defective.  But  I  have 
already  shown  the  vagueness  and  uncertainty  of  all  such  deductions, 
which  still  lack  a  tangible  and  well-established  basis,  and  I  believe 
this  is  also  true  of  the  above  suggestions. 

Purely  nervous  polyphagia  is  a  very  rare  occurrence ;  naturally 
I  exclude  those  gluttons  of  whom  the  old  and  new  books  on  "  gas- 
trosophy  "  are  full ;  but  I  mean  those  really  morbid  conditions  which 
usually  follow  tangible  lesions,  and  in  the  discussion  of  which  these 
cases  will  be  found. 

Nervous  anacidity  of  the  gastric  juice  is  not  as  rare  as  it  would 
appear  after  searching  through  the  literature.  I  have  repeatedly 
found  it  in  hysterical  persons  (see  the  case  of  hysterical  gastralgia, 
p.  412).  I  have  also  observed  it  in  neurasthenics  in  Avhom  there 
was  no  reason  for  suspecting  an  organic  disease  of  the  stomach. 

said  that  for  two  years  he  had  not  passed  his  stools  per  anum,  but  at  six  o'clock 
each  evening  he  passed  a  stool  by  his  mouth.  The  man  was  under  observation  only 
two  days,  but  his  statement  was  corroborated.  At  times  the  evacuation  took  place 
without  any  effort;  at  others  they  occurred  during  a  nervous  attack  with  slight 
convulsions  and  pain  in  the  oesophagus. — Tr.] 


428  DISEASES  OF  THE  STOMACH. 

I  shall  restrict  myself  to  the  following  case : 

Mr.  P.,  landed  proprietor  in  Culm,  a  powerful  man  of  Herculean  build, 
forty-three  years  of  age,  said  that  he  had  been  very  nervous  since  the 
death  of  his  wife ;  he  imagined  that  he  had  a  cancer  of  the  stomach ;  there 
were  also  abnormal  sensations  in  the  urethra  and  impaired  sexual  pow- 
ers. His  appetite  was  absent ;  the  stools  were  constipated,  hard,  and  dry. 
His  disposition  was  exceedingly  melancholic. 

On  examination  nothing  could  be  found  except  a  very  marked  sensi- 
tiveness of  the  spinal  column  on  pressure  against  the  spinous  processes 
and  with  the  faradic  brush.  The  stomach  and  m^inary  tract  (catheteriza- 
tion) were  found  normal.  Examination  of  the  test-breakfast  after  ex- 
pression revealed  the  absence  of  free  acid.  He  was  admitted  to  the  sani- 
tarium, where  he  slept  with  potassium  bromide.  Hydrochloric  acid  was 
also  given,  as  well  as  lukewarm  baths  in  the  morning  and  warm  rub- 
bings in  the  evening.  He  was  kept  under  observation  nearly  two  months, 
and  in  that  time  the  stomach-contents,  after  the  test-breakfast,  were  ex- 
amined five  times  at  about  weekly  intervals.  They  were  always  neutral, 
and  contained  the  breakfast  almost  without  any  changes,  but  there  was  no 
mucus. 

Gradually  the  condition  improved,  after  all  kinds  of  sensations  in  the 
soles  of  the  feet,  loins,  larynx,  and  urethra  had  in  the  meanwhile  ap- 
peared. He  was  advised  to  go  to  the  hydriatic  establishment  at  Elgers- 
burg,  where  he  stayed  several  weeks.  Later  on  I  received  a  report  from 
there  that  "Mr.  P.,  the  neurasthenic,  who  leaves  here  to-day,  has  been 
generally  improved  by  the  use  of  lukewarm  half-  and  sitz-baths,  elec- 
tricity, and  massage  ;  yet,  in  spite  of  this,  his  old  complaints  have  re- 
turned, etc." 

Eecently  I  heard  again  from  this  patient.  Although  a  year  and  a 
half  have  elapsed,  his  symptoms  are  about  the  same.  There  are  no  signs 
of  real  loss  of  strength.  We  may  therefore  exclude  organic  diseases,  car- 
cinoma, mucous  catarrh,  etc.  It  is  simply  a  case  of  anacidity  accompany- 
ing neurasthenia,  of  which  I  could  cite  three  or  four  additional  cases. 

I  have  already  given  you  my  opinion  on  the  significance  of  the 
absence  of  free  hydrochloric  acidity  in  Lecture  Y  [p.  187  et  seq\ 

Relaxation  of  the  cardia  and  of  the  pylorus  must  be  considered 
conditions  which  resemble  paralysis. 

Paresis  of  the  cardia  may  give  rise  to  the  annoying  and  trouble- 
some nervous  eructation  (see  above,  under  Eructation,  page  418).  If 
fluids  or  remnants  of  food  are  raised,  as  well  as  gas,  the  condition 
is  called  regurgitation.  In  very  many  persons  small  quantities  of 
chyme  having  a  very  sour  taste  are  raised  after  eating,  but  they  are 
swallowed  at  once ;  this  condition  can  be  called  neither  pathological 
nor  very  annoying.  But  if  it  occurs  frequently,  and  if  larger  quan- 
tities are  regurgitated,  then  they  are  no  longer  swallowed  again  but 


RUMINATION.  429 

are  expectorated ;  true  rumination,  sncli  as  occurs  in  animals,  does 
not  take  place.  This  condition  is  very  annoying  and  may  lead  to 
serious  changes  in  nutrition,  yet  it  may  also  exist  for  years  "without 
any  bad  results.  At  times  will-j)ower  may  succeed  in  repressing  it ; 
yet  I  have  seen  a  young  man  in  whom  neither  will-power  nor  large 
doses  of  bromide  of  sodium  had  any  effect. 

Regurgitation  also  occurs  in  diverticula  of  the  oesophagus ;  here 
it  may  be  due  either  to  the  filling  up  of  the  diverticulum  and  its 
overflowing  into  the  mouth — this  occurs  most  frequently  when  there 
is  a  stricture  below  the  site  of  the  diverticulum — or  the  contents  of 
the  pouch  may  voluntarily  be  raised,  or  rather  pressed  upward,  by 
the  patient. 

At  my  lectures  I  have  frequently  presented  a  patient  with  a  diverticu- 
lum who  was  able  to  raise  its  contents  at  will  by  taking  a  deep  inspiration 
and  bearing  down.  As  lie  restricted  himself  to  fluids,  the  material  which 
he  raised  contained  no  solid  substances ;  the  greater  part  of  it  was  mucus, 
and  by  its  smell  one  could  ascertain  whether  he  had  previously  taken 
coffee,  alcoholic  drinks,  etc.  The  reaction  was  alkaline  or  neutral.  At 
first  there  was  no  odor,  but  recently  the  patient  has  observed  that  what  he 
regurgitates  has  a  slight  foul  smell. 

An  entirely  different  thing  is  Rumination,  Merycismus  [/nrjpvKa^M, 
I  ruminate],  Wiederkduen,  which  has  attracted  the  attention  of  lay- 
men and  physicians  ever  since  antiquity,  and  has  given  rise  to  the 
strangest  theories.  Some  supposed  that  ruminators  were  necessarily 
descended  from  parents  with  horns  ;  *  thus  Fabricius  says,  "  Ex  quo 
forte  datur  nobis  intelligi  parentis  semen  aliquam  habuisse  affini- 
tatem  cum  cornigeris  animalibus  neque  mirum  fuisse  genitum  filium 
simile  quid  a  parente  contraxisse "  (that  is,  the  father  is  said  to 
have  had  a  horn  on  his  forehead) ;  others  imagined  that  these  per- 
sons— at  least  as  infants — must  have  suckled  ruminating  animals  ;  f 
or  even  that  "  they  had  sinful  intercourse  with  a  cow."  For  a  long 
time  the  opinion  prevailed  that  these  persons  certainly  had  stomachs 

*  I  have  taken  these  data  from  the  following  treatises:  Bourneville  and  Seglas, 
Archiv  de  Neurologie,  1883,  p.  86;  Schmidtmann,  loc.  cit.,  p.  183;  Schneider,  Das 
Wiederkauen  beim  Menschen,  Heidelberger  med.  Annalen,  1846,  xii,  S.  251 ;  A. 
Johannesen,  Ueber  das  Wiederkauen  beim  Menschen,  Zeitsehrift  fiir  klin.  Med., 
Bd.  X,  S.  274. 

f  Daniel  Perinetti,  an  eight-year-old  child,  was  said  to  have  been  nourished  by  a 
goat  for  two  years,  and  to  have  ruminated  later  on  in  imitation  of  it. 


430  DISEASES  OF  THE  STOMACH. 

with  different  compartments,  like  ruminants,  till  it  was  finally  shown 
by  autopsies  that  in  the  majority  of  cases  there  were  no  changes  in 
the  stomach  or  CBSophagus. 

As  time  passed  by  these  negative  results  became  more  frequent ; 
but  Schneider  [1846]  was  able  to  report  the  case  of  a  court  coun- 
cilor from  Fulda  who  had  died  at  the  age  of  seventy  years,  at  the  end 
of  the  previous  century,  after  having  ruminated  all  his  life.  In  this 
case  it  was  found  that  the  cardia  was  wide  enough  to  easily  admit 
five  fingers,  and  that  the  stomach  was  enormously  dilated.  Arnold 
(1838)  observed  three  cases  of  rumination  in  which  a  sacculated 
dilatation  of  the  oesophagus  was  found  above  the  cardia  in  the  an- 
trum cardiacum.  Bourneville  and  Seglas  *  (1883)  came  to  the  con- 
clusion that  there  was  no  real  anatomical  change. 

In  fact,  the  manifestations  of  rumination  are  especially  liable  to 
attract  attention.  ]^ot  alone  is  it  remarkable  that,  a  shorter  or  longer 
interval  after  eating,  the  food  returns  to  the  mouth  in  separate  mor- 
sels, unchanged  in  taste,  to  be  chewed  and  swallowed  a  second 
time,  yet  it  is  still  more  wonderful  that  they  should  come  up  in  a 
definite  order,  and  that  they  should  taste  even  better  than  the  first 
time  ;  f  or  that  the  taste  may  be  so  unchanged  that,  as  reported  by 
Peter  Frank,  a  patient  could  distinguish  the  food  in  the  reverse 
order  in  which  he  had  eaten  it  on  the  23revious  day.  It  is  also  stated 
by  Darwin  that  any  particular  dish  which  had  been  eaten  could  be 
regurgitated  at  pleasure.  This  certainly  seems  to  be  almost  super- 
human. No  light  is  shed  by  the  explanation  of  Gallois :{:  that  the 
regurgitated  masses  at  first  consist  of  an  indistinguishable  mixture 
of  fluid  and  solid  ingesta;  but  when  rumination  occurred  during 
the  later  stages  of  digestion  they  would  then  contain  only  solids, 
and  finally  merely  indigestible  remnants  of  food,  like  tendons,  leaves 
of  salad,  etc.  A  simple  explanation  is  that  during  gastric  digestion 
the  fluidified  ingesta  are  removed  from  the  stomach ;  hence,  the 
regurgitated  masses  gradually  contain  more  and  more  solid  sub- 


*  Archiv  de  Neurologie,  1883. 

f  Anthony  Kechy  said,  '•  Indeed,  it  is  sweeter  than  honey,  and  accompanied  by 
a  more  delightful  relish." 

t  P.  Gallois.  Merycisme  et  etude  physiologique  de  la  digestion  stomacale. 
Revue  de  med.,  1889,  No.  3. 


RUMINATION.  431 

stances  wliicli  can  not  be  attacked  by  the  stomach,  and  finally  con- 
sist of  nothing  but  the  latter.  Hence,  the  condition  of  the  regurgi- 
tated food  does  not  depend  on  tlie  wishes  of  the  patient,  but 
upon  the  phase  of  digestion  in  which  rumination  occurs.  Rossier  * 
asked  one  of  these  subjects  to  keep  a  record  of  the  number  of  the 
regurgitated  morsels.  After  breakfast  there  were  six  to  twelve ; 
dinner,  eleven  to  twenty-one ;  supper,  seven  to  sixteen. 

Rumination  must  not  be  confounded  with  the  condition  in  which 
healthy  persons  may  at  will  regui-gitate  the  contents  of  the  stomach  ; 
this  is  simply  due  to  their  ability  to  expel  food  from  the  stomach  in 
the  same  manner  as  in  my  method  of  expression.  It  was  this  fact, 
for  example,  which  led  Montegre  f  to  make  his  investigations  on 
digestion. 

That  rumination  is  due  to  a  neurosis  is  beyond  doubt.  This  is 
corroborated  by  the  well-authenticated  cases  of  heredity — e.  g., 
Windthier's  case  of  a  Swede,  forty-five  years  of  age,  who  had 
ruminated  since  his  thirtieth  year;  his  son  also  began  it  in  his  twenty- 
fourth  year.  Kossier  describes  a  father  and  son,  sixty-five  and 
twenty-four  years  old  respectively.  Another  factor,  imitation,  may 
play  an  important  part ;  this  is  shown  in  the  case  reported  by 
Korner,:|:  where  a  ruminating  governess  gave  it  to  her  two  pupils. 
Additional  weight  is  lent  by  its  relatively  frequent  occurrence  in 
nervous  persons  suffering  from  neurasthenia,  hysteria,  epilepsy,  and 
idiocy,  and  its  cessation  when  the  patients  experience  profound 
emotional  disturbances — passion,  anger,  etc.  The  case  of  Ducasse* 
also  confirms  this ;  this  was  a  young  man  who  had  been  afflicted 
with  this  disorder  from  his  sixth  to  twenty-eighth  year ;  it  was 
lessened  on  the  first  day  after  his  marriage,  and  disappeared  one 
week  after ;  in  other  eases  the  reverse  has  occurred ;  there  are  still 
others  in  whom  the  malady  is  made  worse  by  sexual  excesses. 

The  state  of  nutrition  of  the  patients  is  very  variable.     The  dis- 


*  Rossier.     Merycisme  hereditaire  dependant  d'une  epilepsie.    Annal.  de  la  Soe. 
de  med.  d'Anvers,  avril-mai,  1867. 

f  Montegre.     Experiences  sur  la  digestion.     Paris,  1814. 

X  0.  Korner.    BeitragezurKenntnissder  Rumination  beimMenschen.   Deutsches 
Archiv  fiir  klin.  Med.,  Bd.  33. 

*  Ducasse.     Mem.  de  I'Acad.  royale  de  Toulouse,  tome  iii.    Quoted  by  Schneider, 
loc.  cit. 


432  DISEASES  OF  THE  STOMACH. 

ease  maj  occur  in  all  classes  of  society  and  at  all  ages.  Haste  in 
eating  and  the  swallowing  of  large  morsels  seem  to  be  of  verj  fre- 
quent occurrence  in  this  disorder.  Rumination  may  take  place 
voluntarily  or  involuntarily,  but  its  suppression  causes  pain. 

The  most  varied  speculations  have  been  indulged  in  as  to  its 
cause :  first  a  central  lesion  was  suggested ;  then  a  peripheral  one ; 
some  thought  it  was  due  to  a  relaxation  of  the  cardia;  others  re- 
ferred it  to  a  heightened  sensibility  of  the  mucosa  and  stronger  mus- 
cular contractions  of  the  stomach,  or  even  to  some  peculiar  forma- 
tion of  the  latter  or  of  the  antrum  cardiacum  of  the  oesophagus. 
We  must  confess  that  we  really  know  nothing  of  the  true  etiology 
of  the  affection,  and  it  would  simply  be  a  circumlocution  to  follow 
the  example  of  Deliio,*  who  designates  it  a  "  perverse  and  com- 
bined act  of  motion  "  or  a  reflex  functional  neurosis.  A  study  of 
the  murmurs  of  deglutition  shows  that  there  can  be  no  permanent 
relaxation  of  the  cardia.  Deliio  heard  in  his  patient  a  distinct 
Pressgerdusch  "  which,  according  to  the  generally  accepted  view 
of  the  origin  of  this  murmur,  can  not  be  present  when  the  cardia  is 
paralyzed  "  [see  foot-note,  p.  61].  Distention  of  the  stomach  with 
carbonic-acid  gas  also  showed  that  the  cardia  was  competent.  In 
two  cases  of  my  own  in  which,  at  all  events,  rumination  M-as  not 
very  marked  (possibly  eructation  would  be  the  proper  name),  re- 
peated examination  failed  to  reveal  the  normal  Pressgerdusche  and 
the  Sjyritsgerdusch.  According  to  the  prevailing  views,  this  would 
also  speak  against  a  permanent  relaxation  of  the  cardia ;  on  the 
other  hand,  no  further  proof  is  needed  to  show  that  at  the  time  of 
rumination  the  tone  of  the  cardiac  sphincter  must  be  relaxed,  and 
that  there  must  be  a  paresis,  or  better,  an  unusually  easy  yielding 
of  the  cardia.  Unfortunately,  in  the  patient  who  was  able  to  swal- 
low two  live  gold-fish,  respectively  6|-  and  h^  centimetres  [2f  and 
'2^  inches]  long,  and  to  regurgitate  them  alive  twenty  minutes  after, 
Alt  f  neglected  to  study  the  murmurs  of  deglutition  ;  yet  this  per- 
formance would  seem  almost  impossible  without  a  relaxation  of  the 


*  K.  Dehio.     Ein  Fall  von  Ruminatio  humana.     St.  Petersburger  med.  Woch- 
enschr.,  1888,  No.  1— Einhorn,  New  York  Medical  Record,  1890. 

f  K.  Alt.     Beitrtige  zur  Lehre  A'on  Merycismus,     Berl.  klin.  Wochenschr., 
Nos.  26  and  27. 


RUMINATION.  433 

cardia  and  cesopliagus,  since  it  is  scarcely  possible  that  the  delicate 
fish  could  have  been  squeezed  through  the  narrow  passage  alive. 
ISTaturally  this  does  not  solve  the  question  whether  the  relaxation  is 
permanent  or  temporary ;  yet  to  me  it  seems  justifiable  to  classify 
rumination  among  the  cases  of  insufiiciency  of  the  gastric  sphincters. 
Finally,  both  of  my  cases  were  neurasthenics  (male) ;  and  in  this 
respect  they  agree  with  the  other  cases  which  have  been  reported. 

The  reports  published  recently  in  rapid  succession  by  Alt, 
Boas,*  Jiirgensen,  f  and  Sievers,:}:  have  shed  some  light  on  the 
chemical  processes  in  this  condition ;  they  do  not  agree,  for  hyper- 
acidity and  subacidity  were  each  found  once  and  anacidity  twice. 
From  this  we  may  infer  that  the  changes  in  the  chemical  processes 
of  the  stomach  are  not  an  essential  but  only  an  incidental  feature  in 
the  symptomatology  of  rumination ;  hence  I  would  not  be  at  all 
surprised  if  in  one  and  the  same  patient  varying  degrees  of  acidity 
were  found  under  otherwise  identical  conditions,  since  such  a  vari- 
able relation  is  characteristic  of  many  of  the  neuroses. 

JN^evertheless,  among  the  cases  just  referred  to  relief  was  ob- 
tained by  the  treatment  which  was  indicated  by  the  results  of  the 
chemical  examinations ;  alkalies  were  given  in  one  case  of  Alt  and 
three  of  Sievers,  where  there  was  hyperacidity,  and  acids  in  Boas's 
case  with  subacidity.  These  results  should  be  appreciated  still  more, 
since  every  kind  of  treatment  which  had  previously  been  tried  was 
unsuccessful.  The  only  exception  to  this  was  Bossier,  who  gave 
relief  in  one  case  by  the  internal  administration  of  morphine  in 
increasing  doses  up  to  40  centigrammes  [gr.  vj]  a  day ;  in  another 
patient  in  whom  this  drug  was  powerless  he  succeeded  with  large 
doses  of  opium,  1"5  gramme  [gr.  xxijss.]  !  ?  In  general,  the  best 
treatment  seems  to  be  that  given  in  a  case  described  by  Ponsgen — an 
energetic  will,  and  swallowing  the  food  at  once  when  it  regurgitates, 
without  chewing  it  a  second  time.  Expectoration  of  the  regurgi- 
tated food  may  lead  to  serious  disturbance  of  nutrition,  as  occurred 
in  the  case  reported  by  Sauvage,  of  a  patient  who  had  been  afflicted 
for  thirty  years,  but  whose  confessor  had  ordered  him  to  spit  out 


*  J.  Boas.     Ibid.,  No.  31.  J  Sievers.    Finske  Lakares  Allskapt,  1889. 

f  Chr.  Jiirgensen.     Ibid.,  No.  36. 


434  DISEASES   OP   THE   STOMACH. 

the  regurgitated  masses.  Two  weeks  later  lie  liacl  emaciated  very 
much,  but  he  did  not  improve  till,  at  the  advice  of  a  physician,  he 
returned  to  the  old  habit. 

If  the  existence  of  23aresis  of  the  cardia  in  rumination  is  an  as- 
sumption rather  than  a  demonstrated  fact,  this  is  even  more  appli- 
cable to  incontinence  of  the  pylorus,  which  was  considered  a  special 
nervous  affection,  first  by  L.  de  Sere,'^'  and  more  recently  by  Eb- 
stein.f  It  is  true  that  the  latter  has  positively  demonstrated  that 
the  pylorus  may  be  incompetent  when  unyielding  neoplasms  involve 
this  portion  of  the  stomach  ;  this  was  naturally  to  be  expected,  but 
unfortunately  we  have  no  diagnostic  criteria  by  which  we  may  es- 
tablish the  existence  of  this  condition  as  dependent  upon  atony  of 
the  pyloric  sphincter — i.  e.,  as  a  pure  neurosis — for  an  occasional 
incontinence  of  the  pylorus  is  a  normal  phenomenon.  An  extensive 
experience  will  demonstrate  to  any  one  wdiat  was  first  observed  by 
Kussmaul,  that,  after  introducing  the  tube  into  the  stomach  while 
fasting,  intestinal  contents  or  bile  may  be  obtained  ;  this  occurs  most 
frequently  when  the  patients  have  gone  without  eating  for  a  longer 
period  than  usual.  The  natural  inference  from  this  is  that  the  pylo- 
rus was  not  firmly  closed ;  consequently,  it  will  be  very  difficult  to 
distinguish  its  pathological  occurrence  from  the  physiological.  Fur- 
thermore, Ebstein's  diagnostic  test,  the  rapid  passage  into  the  intes- 
tines of  the  carbonic-acid  gas  which  has  been  artificially  generated 
in  the  stomach,  is  unreliable,  and  is  subject  to  manj  errors.  First, 
the  inflation  of  the  stomach  may  displace  some  coils  of  intestines  up 
against  the  abdominal  wall,  just  as  if  they  had  been  distended  by  the 
passage  of  gas  into  them  from  the  stomach ;  secondly,  different  per- 
sons require  very  varying  quantities  of  effervescing  powder  to  dis- 
tinctly inflate  their  stomachs ;  finally,  the  gastric  contents  may  com- 
bine with  more  or  less  of  the  gas  as  it  is  generated.  Hence  the 
pylorus  maj  be  competent,  in  spite  of  the  negative  result  of  this  test. 

At  all  events,  incontinence  of  tlie  pylorus  is  a  very  rare  occur- 


*  L.  de  Sere.     Du  relachement  dii  pylore.     Gaz.  des  hop.,  1864,  No.  62. 

f  Ebstein.  Ueber  Nichtschlussfahigkeit  des  Pylorus  (Incontinentia  pylori). 
Volkmann's  klin.  Vortrage,  No.  155. — Einige  Bemerkungen  zu  der  Lehre  von  der 
Nichtschlussfahigkeit  des  Pylorus.  Deutsch.  Archiv  fiir  klin.  Med.,  Bd.  xxxvi, 
S.  295. 


ATONY   OF  STOMACH.  435 

rence.  In  the  numerous  cases  in  wliicli  I  have  distended  the  stom- 
ach to  its  utmost  with  air,  I  could  never  distinctly  demonstrate  such 
a  condition  ;  instead  of  that,  the  air  always  escaped  upward  with  ex- 
plosive eructations  whenever  the  tension  became  too  great.  ]^ever- 
theless,  I  believe  that  some  dysj)eptic  disturbances  are  due  to  pyloric 
incontinence  ;  yet  many  more  are  the  result  of  regurgitation  of  the 
intestinal  contents  into  the  stomach  rather  than  a  too  early  passage 
of  the  chyme  into  the  duodenum.  On  the  other  hand,  I  agree  fully 
with  Ebstein  and  Zeckendorf,*  that  the  acute  intestinal  tympanites 
of  hysterical  persons  may  be  largely  due  to  the  rapid  passage  from 
the  stomach  into  the  intestines  of  air  which  has  been  swallowed ; 
hence  the  pylorus  must  necessarily  have  been  incompetent. 

Another  fact  which  I  have  repeatedly  observed  may  possibly  be 
of  importance  in  the  etiology  of  pyloric  incontinence.  ]^ot  infre- 
quently we  encounter  persons  whose  stomachs  are  found  empty  after 
the  usual  interval  (an  hour,  or  sometimes  even  forty-five  minutes) 
following  the  test-breakfast ;  yet,  by  pouring  in  water,  we  may  easily 
convince  ourselves  that  the  apparatus  of  expression  or  asjjiration  is 
intact.  In  these  cases  the  chyme  has  passed  unusually  early  into 
the  duodenum ;  but  it  is  still  doubtful  whether  this  is  due  to  a 
heightened  peristalsis  which  has  overcome  the  normal  closure  of  the 
pylorus,  or  whether  there  is  an  incompetence  of  this  sphincter. 

Atony  of  the  stomacli  is  an  important  neurosis  to  which  sufficient 
importance  has  not  yet  been  attached.  We  have  already  encount- 
ered this  condition  and  its  results  as  an  accompanying  symptom  of 
manifold  dyspeptic  disturbances ;  but  atonic  states  of  the  gastric 
musculosa  may  undoubtedly  occur  as  a  primary  neurosis,  as  an  inde- 
pendent disorder  of  the  innervation  of  the  nerve-centers  regulating 
the  peristalsis  of  the  stomach  ;  these  may  occur  either  in  loco  affec- 
tionis  or  in  the  central  nervous  system,  and  are  frequently  the  cause 
of  the  dyspeptic  troubles  resulting  therefrom.  It  is  superfluous  to 
speak  in  detail  about  the  origin  of  this  condition  as  a  result  of  in- 
sufficient or  too  tardy  movement  of  the  chyme,  since  we  have  already 
frequently  observed  this  reciprocal  relation  of  cause  and  effect.     I 


*  Zeckendorf.     Ueber  die  Pathogenese  der  Baucbtympanie.     Dissertation,  Got- 

tingen,  1883. 

28 


436  DISEASES  OP  THE  STOMACH. 

simply  wish  to  distinctly  state  once  more  that  I  consider  "  atony  " 
to  include  a  disturbance  of  the  gastric  motor  function  only,  not  of 
its  secretory ;  in  other  words,  it  is  a  lack  of  agreement  between  the 
power  of  the  muscular  force  of  the  stomach  and  the  task  to  be  ac- 
complished by  it — i.  e.,  it  is  an  insufficiency  of  the  stomach  (Rosen- 
bach).  Otherwise  we  may,  like  von  Pfungen,*  include  three  fourths 
of  all  the  lesions  of  the  stomach  under  this  title,  and  yet  not  obtain 
a  clear  conception  of  its  relations. 

Atony  may  be  partial  or  complete,  depending  upon  the  involve- 
ment of  the  fundus  or  pylorus  or  the  entire  stomach.  I  consider 
this  classification  premature,  for  it  is  based  upon  the  independence 
of  the  several  portions  of  the  stomach  which  has  recently  been  re- 
peatedly maintained.  I  wdll  admit  the  value  of  the  experiments  of 
Schift,  von  Hofmeister,  and  Schiitz  upon  the  movements  of  the 
stomach,f  and  also  the  observations  of  von  Pfungen  :|:  upon  a  patient 
who  had  undergone  the  operation  of  gastrotomy  ;  according  to  these 
experiments,  the  motor  power  of  the  body  of  the  stomach  is  about 
one  third  as  great  as  that  of  the  antrum  pylori ;  while  the  function 
of  the  latter  is  especially  to  expel  the  chyme,  that  of  the  former  is 
the  trituration  of  the  ingested  food.  But  I  maintain  that  we  know 
so  little  about  the  movements  of  the  stomach  in  pathological  cases 
that  we  may  be  happy  to  be  able  even  to  recognize  the  existence  of 
these  disturbances  as  such.  Furthermore,  I  can  not  see  what  is 
gained  by  such  a  distinction  between  aton}^  of  the  pyloric  portion 
and  of  the  body  of  the  stomach ;  for,  so  far  as  clinical  effects  are 
concerned,  the  latter  will  always  be  the  more  important  and  causal 
factor.  Where  there  is  no  movement  in  the  body  of  the  stom- 
ach its  absence  can  not  be  replaced  by  the  peristalsis  of  the  an- 
trum pylori,  be  the  latter  ever  so  powerful ;  but  if  a  normal  or 
even  heightened  peristalsis  of  the  fundus  be  associated  with  an 
atonic  condition  of  the  pyloric  portion,  there  can  be  no  obstruc- 
tion to  the  expulsion  of  the  chyme  ;  on  the  other  hand,  this  must 
be  more   easily  accomplished  than  normally,  since  an  atonic  state 


*  R.  PreiheiT  v.  Pfungen.     Ueber  Atonie  des  Magens.     Klinische  Zeit-  und 
Streitfragen.    Vienna,  1887. 

t  Vide  Ewald.    Klinik,  etc.,  I.  Theil.,  3.  Auflage,  S.  78. 
X  Log.  cit.,  p.  261. 


GASTRIC   NEURASTHENIA.  437 

of  this  portion  of  tlie  mnsculosa  of  the  stomach  would  be  incon- 
ceivable without  a  coincident  diminution  of  the  tone  of  the  true 
pyloric  sphincter  which  is  so  closely  associated  with  it ;  consequently, 
tlie  nniscular  power  of  the  remainder  of  the  stomach  can  easily 
overcome  the  resistance  of  the  "  dead  channel "  thus  formed.  In 
such  cases  we  might  possibly  suppose  that  where  this  relaxation  of 
the  pyloric  portion  begins  a  closure  of  some  kind  might  be  effected 
by  the  contraction  of  the  adjacent  circular  fibers  of  the  stomach, 
and  thus  none  of  the  chyme  will  pass  on  into  the  intestines  in  spite 
of  the  apparently  vigorous  peristalsis.  This  is  how  von  Pfungen 
attempts  to  explain  a  case  of  this  kind  which  had  been  reported  by 
Kussmaul.*  Such  suppositions,  however,  lead  us  into  the  broad 
field  of  speculation,  from  which  we  must  keep  aloof  as  far  as  pos- 
sible. 

III.  Mixed  Form  of  Gastric  JSTeuroses. 

Neurasthenia  Gastrica  (Nervous  Dyspepsia). — The  condition  which 
under  the  name  of  nervous  dyspepsia,  has  recently  been  the  subject 
of  so  much  discussion,  is,  in  my  opinion,  only  a  complex  form  in 
which  the  neuroses  already  described  in  the  preceding  pages  take  a 
more  or  less  prominent  part,  but  which  is  at  the  same  time  charac- 
terized by  an  active  participation  of  the  entire  gastro-intestinal  tract. 

But  now  it  is  quite  difficult  to  include  these  conditions  within 
one  clearly  defined  clinical  picture.  It  is  almost  like  trying  to  grasp 
a  medusa  which  is  dissipated  under  our  grasp.  For,  if  we  adhere 
closely  to  that  which  is  indicated  by  its  name,  we  can  include  only 
actual  digestive  disturbances,  dyspeptic  conditions  which  lead  to  a 
distinct  change  in  the  chemical  functions  of  the  stomach.  But  if 
we  follow  the  conception  of  nervous  dyspejosia,  which  was  first  an- 
nounced by  Leube  in  his  classical  work,f  that  it  causes  digestive 
complaints  without  producing  digestive  disturbances — i.  e.,  without 
altering  the  chemical  functions  of  the  stomach — then,  as  Eossbach 
has  very  properly  said,  we  have  a  condition  very  much  like  dys- 
pepsia, but  not  dyspepsia.  Every  one  will  at  once  feel  how  strained 
such  a  nomenclature  is. 

*  Kussraaul.     Deutsch.  Arch.  f.  klin.  Med.,  Bd.  vi,  S.  470. 
t  III.  Congress  f  iir  innere  Mediein  zu  Berlin. 


438  DISEASES  OF  THE  STOMACH. 

According  to  Leube,"^  nervous  dyspepsia  is  a  group  of  symptoms 
essentially  of  a  cerebral  nature,  wliicli  are  due  to  an  abnormal  irri- 
tability of  the  sensory  nerves  of  the  stomach  toward  the  normal 
digestive  processes,  and  which  are  especially  manifested  by  the 
symptoms  which  I  have  already  grouped  together  among  the  sen- 
sory phenomena  caused  by  irritation. 

On  the  other  hand,  Stiller  includes  under  this  title  of  nervous 
dyspepsia  all  those  conditions  in  which  there  is  a  predominance  of 
digestive  disturbances  which  are  reflected  back  upon  the  stomach 
from  and  by  means  of  the  central  nervous  system  and  the  sympa- 
thetic res23ectively,  and  which  may  incidentally  cause  definite  changes 
in  its  functions.  "Whereas  the  former  writer  proceeds  from  the 
center  of  the  circle  to  the  periphery,  the  latter  goes  in  the  reverse 
direction,  from  the  periphery  to  the  center.  Furthermore,  while 
the  former  claims  that  the  true  peptic  acti\'ity  of  the  stomach  is 
unchanged,  the  latter  maintains  that  it  is  altered  under  certain  con- 
ditions, and,  in  fact,  in  the  majority  of  cases. 

In  this  dilemma  it  would  be  difficult  to  follow  the  usual  course 
and  say  that  the  truth  lies  midway  between  these  two  views,  for  in 
a  certain  sense,  or  rather  with  certain  restrictions,  both  of  them  may 
be  correct.  There  are  some  cases — i.  e.,  the  rarer  cases  of  Leube — 
which  correspond  to  the  picture  of  nervous  dyspepsia ;  but  I  believe 
that  this  group  will  gradually  grow  smaller  and  smaller  with  the 
increasing  delicacy  of  the  methods  of  investigating  the  peptic  pow- 
ers of  the  stomach.  On  further  examination,  Leube's  criterium  of 
normal  digestion — i.  e.,  the  stomach  must  be  empty  six  to  seven 
hours  after  the  test-meal — has  proved  to  be  insufficient.  Eosenbach, 
Riegel,  E.odzajewski,f  myself,  and  others  have  emphasized  the  un- 
certainty of  this  test.  After  a  careful  study  of  the  digestive  pro- 
cesses, I  have  found  changes  in  the  chemical  functions  in  quite  a 
large  number  of  cases  in  which  the  nervous  symptoms  were  the 
prominent  feature.  Furthermore,  we  must  not  forget  that  our  pres- 
ent methods  of  chemical  examination  are  still  relativelv  crude,  and 


*  Leube.  Ueber  nervose  Dyspepsie.  Deutsches  Archiv.  fiir  klin.  Mediein,  Bd. 
sxiii,  1879. 

f  Rodzajewski.  Ueber  die  Digestiondauer  im  Magen  als  diagnostische  Methode. 
Petersburg,  med.  Wochensehr.,  1885,  Nos.  32,  33. 


GASTRIC  NEURASTHENIA.  439 

give  us  absolutely  no  information  concerning  the  amount  of  pe^^sin 
secreted,  and  very  little  about  the  intensity  of  absorption  and  the 
strength  of  motion.  Hence,  we  can  only  ascertain  certain  gross 
changes,  while  there  is  surely  quite  a  large  number  of  alterations 
which  escape  us  because  they  lie  beyond  our  present  limits.  The 
same  may  be  true  of  anatomical  changes,  Jiirgens*  has  made  an 
important  contribution  upon  this  point.  In  forty-one  patients  who, 
while  alive,  had  complained  of  vague  dyspeptic  disturbances,  a  com- 
plete degeneration  of  Meissner's  and  Auerbach's  plexuses  was  dis- 
covered ;  in  this  way  he  gave  a  tangible  anatomical  basis  to  these 
cases  of  dyspepsia,  many  of  which  had  been  diagnosticated  as  "  re- 
flex dyspepsia,"  Furthermore,  "  where  the  disturbance  was  more  of 
a  sensory  character,"  he  found  "  a  degeneration  of  the  muscularis 
mucosae  of  the  stomach  and  of  the  intestines  also,  and  a  pronounced 
formation  of  varices  in  the  intestinal  walls,  the  exact  examination 
of  which  revealed  a  degeneration  not  alone  of  the  muscular  fibers 
of  the  veins,  but  also  of  the  sensory  nerves  and  of  the  branches  of 
Meissner's  plexus  in  the  vicinity,"  Unfortunately,  the  results  of 
the  detailed  investigations  have  not  yet  been  published ;  but,  if  the}'- 
prove  correct  and  are  pursued  further,  the  domain  of  nervous  dys- 
pepsia will  also  be  curtailed  on  this  side. 

On  the  other  hand,  in  the  majority  of  cases  we  can  discover  no 
changes  in  the  nerves  outside  of  the  stomach,  of  a  direct  or  reflex 
nature,  which  may  be  referred  to  this  viscus,  or  may  give  rise  to 
immediate  disturbances  of  the  gastric  digestion. 

In  either  case  the  clinical  symptoms  of  this  condition  will  always 
consist  of  the  manifestations  which  I  have  already  described  as  those 
of  irritation  or  paralysis,  a  mosaic  in  which  now  one  stone,  now  an- 
other, will  be  lacking ;  sometimes  one,  sometimes  another,  will  be 
especially  prominent ;  but  they  will  never  be  firmly  fixed  together, 
and,  like  man  himself,  will  always  present  a  kaleidoscopic  pict- 
ure. There  is  only  one  characteristic  feature,  that,  taken  all  in  all, 
the  symptoms  are  usually  mild,  and  severe  forms  of  gastralgia 
and  cramps,  nervous  vomiting,  polyphagia  and  bulimia,  do  not 
occur. 

*  Jiirgens.     Verhandlungen  des  III.  Congresses  iiir  innere  Medicin,  S.  253, 


440  DISEASES   OF   THE  STOMACH. 

In  all  these  patients  the  symptoms  of  imperfect  intestinal  di- 
gestion will  always  be  found  associated  with  those  dne  to  changes 
in  the  gastric  functions.*  In  some  cases  the  symptoms  of  imper- 
fect intestinal  digestion  are  not  well  marked,  and  are  restricted  to 
the  consequences  of  lessened  or  increased  peristalsis — usually  con- 
stipation, less  frequently  diarrhoea — or  the  stools  may  be  normal  but 
absorption  is  disturbed ;  such  j^atients  will  emaciate  continuously  in 
spite  of  a  good  apj^etite,  etc.  Is^ot  very  long  ago  attention  was  di- 
rected to  these  cases  by  Mobius.f 

In  other  cases  the  intestinal  symptoms  are  so  well  marked  that 
one  might  be  tempted  to  group  them  into  a  distinct  class,  as  was 
done  by  Cherchewsky.;}:  Here,  along  with  mild  gastric  disturbances, 
we  observe  anorexia,  re23ugnance  toward  taking  food,  coated  tongue, 
mild  nausea — in  short,  symptoms  which  might  not  inaptly  be  desig- 
nated those  of  visceral  neuralgia.  The  bowels  are  usually  consti- 
pated, and  there  are  severe  pains  in  the  abdomen,  either  spread 
diffusely  or  recognizable  as  separate  painful  spots.  Rarely  the  ab- 
domen is  retracted ;  as  a  rule,  it  is  quite  distended  and  tympanitic, 
sometimes  even  to  a  marked  degree,  while  the  free  escape  of  flatus 
causes  great  torture  to  the  sufferer.  The  gas  which  may  escape 
either  by  mouth  or  by  rectum  has  caused  this  condition  to  be  called 
flatulent  dyspepsia.  In  addition  there  are  also  general  nervous 
symptoms  like  those  observed  in  the  gastric  form,  except  that  they 
are  usually  more  severe  and  even  at  times  alarming. 

If  you  will  recall  wliat  was  said  in  the  introduction  to  this  part 
about  the  innervation  of  the  stomach  and  intestines,  the  mutual 
transition  of  the  symptoms  of  these  viscera  ought  to  occasion  no 
surjDrise.  The  close  connections  of  the  numerous  plexuses  of  the 
intestines  and  the  fibers  of  the  vagi,  splanchnics,  and  the  vai'ious 
sympathetic  ganglia,  necessarily  cause  the  involvement  of  tlie  one  to 


*  One  of  my  patients  wrote  to  me  that  "  I  must  complain  most  of  a  feeling  of 
oppression  while  walking,  bitter  taste  in  the  mouth,  and  obstinate  constipation." 
The  bitter  taste  in  the  mouth  is  frequently  replaced  by  an  exceedingly  annoying 
dryness  and  burning  sensation. 

f  P.  Mobius.  Ueber  nervose  Verdauungsschwache  des  Darms.  Centralblatt 
fiir  Nervenheilkunde  von  Erlenmeyer,  vii.  Jahrgang,  1884,  No.  1. 

X  Cherchewsky.  Contribution  a  la  pathologie  des  nevroses  intestinales.  Revue 
de  medecine,  1884,  No.  3. 


GASTRIC  NEURASTHENIA.  441 

be  followed  by  a  disturbance  of  the  otlier,  no  matter  whether  the 
cause  is  located  centrally  or  peripherally. 

Therefore,  I  have  proposed  the  name  neurasthenia  gastrica^  or 
vago-symjKithlca,  for  this  entire  group  of  symptoms ;  it  may  be  s]ib- 
divided  into  a  gastric  and  an  intestinal  form,  according  to  the  viscus 
which  is  especially  iiivolved.*  I  consider  this  name  is  much  better 
than  the  expression  nervous  dyspepsia,  because  it  corresponds  more 
closely  to  the  nature  of  the  affection,  and  my  liking  for  the  latter 
designation  has  by  no  means  been  lessened  by  the  reasons  given  by 
Leydenf  in  a  splendid  paper  on  this  theme.  On  the  contrary,  it 
seems  to  me  better  and  more  suitable  to  the  nature  of  the  lesion  to 
leave  out  the  "  dyspepsia"  altogether  ;  for  a  deficiency  in  the  peptic 
powers  of  the  stomach  is  either  absolutely  lacking  or,  at  all  events, 
if  present  plays  a  very  subordinate  part. 

As  I  have  already  said,  gastric  neurasthenia  is  a  complex  of  the 
various  nervous  disturbances  already  described,  and  therefore  these 
can  give  no  specific  and  characteristic  data. 

This  is  also  true  of  R.  Burkart's  painful  points  in  the  abdomen, 
which  have  already  been  described  [page  407].  There  is  nothing 
about  them  which  is  characteristic  of  gastric  neurasthenia.  They 
can  not  be  mistaken  for  gastralgias,  enteralgias,  and  the  painful 
sensations  in  the  abdominal  parietes ;  the  latter  not  infrequently 
radiate  from  the  infrasternal  depression  as  lancinating  pains,  and 
might  well  be  called  epigastralgic,  as  proposed  by  Briquet. 

Leube  has  called  attention  in  his  classical  work  :|:  to  the  fact  that 
the  symptoms  connected  with  digestion  are  nearly  always  preceded 
by  manifestations  of  a  general  nervousness  or,  as  it  is  now  desig- 
nated, neurasthenia. 

The  writers  who  have  since  investigated  the  subject  have  laid  a 
different  stress  upon  this  fact,  according  to  the  standpoint  which 
they  have  taken.  Undoubtedly  there  are  cases  in  which  no  cause 
can  be  discovered — Fenwick*  claims  this  for  the  majority  of  his 


*  Ewald.     Verhandlungen  des  III.  Congresses  fiir  innere  Mediein. 

f  E.  Leyden.     Ueber  nervose  Dyspepsie.     Berl.  klin.  Wochensehr.,  1885,  No.  30. 
X  Leube,  loc.  cit. 

*  Fenwick.     On  Atrophy  of  the  Stomach  and  on  the  Nervous  Affections  of  the 
Digestive  Organs.     London.  1880. 


442  DISEASES  OP    THE  STOMACH. 

observations — but  surely  tliere  are  very  few  patients  indeed  in  wliom 
the  cliaracteristics  of  a  nervous  disposition  can  not  be  discovered. 
Either  nervous  diseases  are  hereditary  in  the  family,  or  the  nervous 
system  has  been  very  severely  taxed  in  some  way  or  another — pro- 
found emotional  excitement,  business  cares,  severe  mental  exertion, 
sexual  excesses — or  the  condition  which  we  call  cerebral  or  spinal 
irritation,  or  any  other  affection  of  the  nervous  system  bordering 
upon  hysteria,  has  preceded  it.  Thus,  I  have  had  under  my  treat- 
ment for  a  long  time  a  young  man,  eighteen  years  old,  whose  father 
suffered  from  pronounced  spinal  irritation.  Another  case  was  an 
old  gentleman  who  had  all  the  symptoms  of  a  well-marked  neurosis 
of  the  intestinal  tract,  after  having  suffered  for  years  from  peculiar 
nervous  symptoms,  which  were  always  associated  with  irregularities 
of  intestinal  digestion.  There  are  also  some  cases — their  number  is 
very  limited- — in  which  intestinal  neuroses  are  developed  without 
these  prodromata.  By  watching  such  patients  for  a  longer  period 
w^e  will  usually  be  a])le  to  observe  other  neurasthenic  symptoms.  I 
Imve  frequently  seen  a  young  lady  in  whom  the  condition  which  at 
first  could  only  be  called  gastric  neurasthenia  was  aggravated  on 
account  of  the  cessation  of  menstruation,  and  finally  became  hys- 
teria, with  especial  prominence  of  the  signs  of  gastralgia  and  enter- 
algia.  However,  such  an  occurrence  is  manifestly  very  rare,  and 
warrants  the  suspicion  that  it  was  hysteria  from  the  beginning ;  in 
fact,  all  these  conditions  now  under  discussion  were  formerly  in- 
cluded under  this  disease,  l^aturally,  they  have  been  known  for  a 
long  time,  but  their  exact  description,  and  the  chemical  demonstra- 
tion of  the  integi-ity  of  the  gastric  juice,  is  an  achievement  of  recent 
times,  due  especially  to  the  labors  of  Leube. 

At  this  place,  however,  I  should  like  to  state  that  the  same  nerv- 
ous states  which  constitute  the  prodron.ata  of  the  dyspeptic  con- 
dition may  also  become  very  prominent  during  the  course  of  the 
latter.  I^ot  alone  are  there  pains  in  the  head  and  back,  weariness 
of  the  limbs,  etc.,  but  these  patients  are  very  gloomy  and  pessimis- 
tic, worry  unnecessarily,  and  lose  what  little  ambition  they  still  pos- 
sess. One  of  my  patients  complained  of  a  weak  memory  and  in- 
ability to  concentrate  his  thoughts ;  another  suffered  very  severely 
from  vertigo  during  every  exacerbation  of  his  dyspepsia.     At  the 


GASTRIC  NEURASTHENIA.  443 

same  time  the  pulse  became  small  and  rapid,  the  hands  and  feet 
were  cold  and  livid,  and  treml)led,  there  was  palpitation  of  the 
heart  with  oppression  and  dyspncjea,  which  became  worse  on  getting 
up  or  walking  ;  these  symptoms  increased  to  a  most  intense  fear  of 
impending  death,  till  suddenly  relief  was  brought  by  the  passage  of 
flatus.  Althougli  the  patient,  who  was  a  well-educated  gentleman, 
moving  in  the  highest  circles,  knew  how  the  attack  would  end,  he 
was,  nevertheless,  utterly  unable  to  overcome  the  feeling  of  impend- 
ing death. 

In  all  these  cases  I  wish  to  state  emphatically  that  the  lesions  are 
dyspeptic  conditions  upon  a  neurotic  basis,  never  concomitant  symp- 
toms of  really  demonstrable  injuries  of  the  central  nervous  system — 
6.  g.,  gastric  crises  of  tal:)es  dorsalis,  diffuse  and  localized  cerebral 
lesions,  ailments  of  the  peripheral  nerves,  etc. ;  or  what  may  occur  as 
reflex  neuroses  in  chlorosis,  menstrual  disorders,  uterine  and  ovarian 
diseases,  and  intense  psychical  excitement  (when  they  are  manifested 
as  nervous  diarrhoea  or  constipation).  As  opposed  to  tlie  chronic 
and,  if  I  may  so  express  it,  the  milder  character  of  gastric  neuras- 
thenia, these  conditions  take  the  shape  of  acute,  rapidly  developed 
attacks,  accompanied  by  very  intense  symptoms,  which  may  either 
occur  once  or  return  periodically.  Such  attacks  are  described  in 
Richter's  monograph  ;  *  Leyden  f  has  also  published  a  series  of  very 
well  marked  examples.  In  my  opinion  the  only  relation  which  they 
bear  to  neurasthenia  gastrica  is  that  they  can  not  be  grouped  with 
those  forms  of  psychoses  or  neuroses  in  which  anatomical  lesions  of 
the  central  nervous  system  can  not  be  dem.onstrated  with  the  meth- 
ods thus  far  at  our  disposal. 

Although  we  can  not  positively  say  that  real  pathological  ana- 
tomical changes  are  lacking,  yet  we  can  usually  exclude  great  altera- 
tions in  the  chemical  functions,  even  though  this  is  not  always  justi- 
fiable. In  many  cases  an  indigestion  of  short  or  long  duration,  a 
mild  catarrh,  frequently  recurring  hyperseraia,  and  the  like  have 
surely  been  the  primary  cause  of  the  manifestation  of  the  nervous 


*  Richter.  Ueber  nervose  Dyspepsie  und  nervose  Enteropathie.  Berliner  klin. 
Wochenschr.,  1882,  No.  13. 

f  Leyden.  Ueber  periodisches  Erbrechen  (gastrische  Crisen).  Zeitschr.  fiir 
klin.  Med.,  Bd.  iv,  1882. 


444  DISEASES  OP  THE  STOMACH, 

symptoms  in  the  digestive  organs.  Indeed,  such  injurious  condi- 
tions may  recur  during  the  course  of  the  disease,  and  may  produce 
a  temporary  aggravation  thereof,  because  tliey  are  added  to  the  fac- 
tors already  existing.  But  if  we  encounter  leucorrhoea  or  dyspeptic 
disturbances  during  chlorosis,  or  if  we  see  retinal  changes  in  Bright's 
disease,  we  will  never  consider  these  conditions  as  anything  but 
symptoms  of  a  general  malady. 

In  my  opinion,  there  can  be  no  doubt  tliat  these  dyspeptic  con- 
ditions are  the  manifestations  of  general  neurasthenia.  In  rare 
cases  this  may  be  developed  only  in  the  nerves  of  the  stomach  and 
intestines,  and  apparently  the  lesion  is  in  one  of  the  peripheral 
nerves.  In  the  vast  majority  of  cases  these  local  symptoms  are  com- 
bined with  others  of  a  nervous  nature,  and  among  which  they  oc- 
cupy a  pre-eminent  place. 

For  the  diagnosis  of  dyspeptic  neurasthenia  there  are  no  single 
characteristic  symptoms.  Therefore  it  can  not  be  made  simply  from 
the  results  of  one  examination,  and  the  complaints  of  the  patient  at 
that  time ;  the  more  so,  since  not  infrequently  oi'ganic  lesions  may 
go  hand  in  hand  with  neurasthenic  conditions.  A  correct  diagnosis 
is  possible  only  after  a  prolonged  observation  of  the  course  of  the 
disease,  discovery  of  the  causal  factors,  the  failure  of  all  measures 
directed  toward  suspected  organic  diseases  of  the  stomach  and  intes- 
tines, and  a  proper  estimation  of  all  the  signs  of  neurasthenia  which 
may  be  present.  As  Burkart  has  rightly  suggested,  particularly 
great  value  is  to  be  laid  upon  the  peculiar  character  of  the  indi- 
vidual symptoms,  on  account  of  their  mutual  relations  to  one  an- 
other, and  their  changeable  occurrence. 

I  would  also  like  to  direct  attention  to  the  following :  First,  the 
gastralgic  pains  are,  as  a  rule,  diffuse,  and  do  not  have  that  distinct, 
sharply  localized  character  observed  in  ulcer  or  cancer  of  the  stom- 
ach. They  are  also  much  less  dependent  upon  taking  food,  although 
this  relation  is  also  very  variable  in  carcinoma. 

Secondly,  vomiting  occurs  very  rarely  in  gastric  neurasthenia. 
When  it  does  occur,  it  consists  of  mucus  mixed  with  bile  and  rem- 
nants of  food  in  various  stages  of  digestion,  but  never  of  bloody  or 
decomposed  masses.  It  is  distinguished  from  hysterical  vomiting 
by  the  ease  and  regularity  with  which  tlie  latter  usually  occurs. 


GASTRIC  NEURASTHENIA.  44.5 

The  taste  of  the  vomit  is  not  offensive  but  bitter  ;  I  am  inclined  to 
ao-ree  with  Liebreich  that  the  taste  in  these  cases  is  due  not  to  bile 
but  to  peptones,  which  are  well  known  to  have  a  very  sharp  and  bit- 
ter taste.  In  belching,  with  the  regurgitation  of  acrid  masses,  this 
is  undoubtedly  the  case. 

Thirdly,  the  stools — of  which  I  have  examined  a  large  number 
in  the  course  of  time — have  the  usual  changeable  character  described 
by  Lambl,  and  later  by  Nothnagel.*  In  no  case  did  I  find  an  un- 
usual quantity  of  undigested  remnants  of  food  or  mucus,  or  even  of 
blood.  The  form  of  the  faeces  is  also  very  variable.  I  have  ob- 
served nothing  of  a  typical  character,  and  it  was  only  rarely  that  I 
saw  the  ribbon-shaped  stools  ujDon  which  Cherchewsky  lays  so  much 
stress. 

Concerning  the  differential  diagnosis,  I  shall  not  speak  of  the 
neoplasms,  ulcers,  strictures,  etc.,  which  may  be  recognized  by  pal- 
pation, inspection,  or  by  very  characteristic  symptoms,  but  instead  I 
shall  invite  your  attention  to  the  following  points  : 

Leube  has  recommended  the  so-called  digestion-test  as  an  aid  in 
the  differential  diagnosis.  According  to  this  writer,  in  health  and 
in  neurasthenia  gastrica  the  stomach  should  be  empty  seven  hours 
after  taking  a  simple  meal,  and  the  wash-water  after  lavage  should 
contain  no  traces  of  food.  I  will  admit  that  this  rule  is  true  of  the 
majority  of  cases,  but  the  exceptions  to  it  I  have  already  given  {vide 
sttpra).  Leube  f  himself  speaks  of  two  cases  out  of  six  examples  of 
dyspeptic  neurasthenia  in  which  the  stomxach-contents  were  undi- 
gested in  the  seventh  hour  after  eating,  and  contained  no  acid.  On 
the  other  hand,  I  have  found  the  stomach  empty  at  this  time  in  gas- 
tric catarrhs,  ulcers,  and  cancer  of  the  stomach.  Therefore,  although 
the  empty  condition  of  the  stomach  after  this  interval  is  usufJly 
indicative  of  a  normal  condition,  it  by  no  means  gives  absolutely 
certain  conclusions. 

The  same  is  true  of  the  chemical  examination  of  the  contents  of 
the  stomach  which  have  been  obtained  at  an  earlier  period.     Even 

*  Nothnagel.  Beitrage  zur  Physiologie  und  Pathologie  des  Darmes.  Berlin, 
1884. 

f  W.  Leube.  Beitrage  zur  Diagnostik  der  Magenkrankheiten.  Deutsch.  /irchiv 
fiir  klin.  Med.,  Bd.  xxx. 


446  DISEASES  OP  THE   STOMACH. 

ill  very  well  marked  clironic  catarrhs,  where  there  could  be  no  sus- 
picion even  of  a  nervous  origin,  in  ulcer,  and  also  in  carcinoma,  I 
have  found  gastric  juices  which  had  the  normal  percentage  of  acid 
and  digestive  powers,  as  ascertained  with  our  modern  methods  of 
examination.  In  fact,  I  am  convinced  that  we  should  avoid  going 
too  far  in  drawing  conclusions  from  the  results  of  the  chemical  ex- 
amination of  the  gastric  juice,  and  we  should  always  bear  in  mind 
that  a  series  of  factors  participate  in  the  functions  of  the  living 
organ  which  we  can  not  reproduce  in  our  crucibles  and  retorts,  and 
can  not  recognize  with  our  chemical  reagents. 

Where  the  diagnosis  is  doubtful  concerning  the  possibility  of  a 
gastric  ulcer,  there  is  an  additional  factor  to  which  I  always  pay 
attention — i.  e,,  for  the  reasons  given  on  page  260,  I  am  afraid  to 
introduce  the  stomach-tube,  and  I  thus  avoid  the  risk  of  causing  a 
perforation  for  the  sake  of  information  which  may  be  doubtful ; 
therefore,  it  seems  much  more  important  to  me  to  treat  the  suspected 
ulcer  with  aj)proj)riate  remedies,  and  let  the  diagnosis  depend  upon 
the  results  of  such  a  course  of  treatment. 

Indeed,  we  should  endeavor  to  realize  the  fact  that  in  very  many 
cases  it  is  impossible  to  recognize  a  neurosis  at  the  first  glance,  and 
that  only  prolonged  observation,  a  very  carefully  taken  history,  and 
a  consideration  of  the  general  condition  will  strengthen  the  diag- 
nosis and  exclude  ulcer,  primary  or  secondary  engorgement  of  the 
liver,  and  even  carcinoma  or  chronic  tubercular  processes.  Inter- 
costal neuralgia  has  also  given  rise  to  errors ;  and  although  I  have 
never  met  such  a  case,  which  must  necessarily  be  rare,  it  should 
nevertheless  always  be  borne  in  mind. 

The  prognosis  and  treatment  of  neurasthenia  dyspeptica  may 
almost  be  inferred  from  the  nature  of  the  aft'ection.  It  would  be 
easy  to  subdue  the  functional  anomalico  which  might  be  present  if 
they  were  not  always  reproduced  by  their  central  causes.  The  frog- 
nosis  is  as  uncertain  here  as  it  is  in  all  neurasthenic  affections. 
Some  cases  are  quite  rapidly  cured  by  suitable  treatment,  and  may 
remain  well  permanently  or  temporarily  ;  but  there  are  others  which 
for  years  resist  all  the  efforts  of  rational  therapeutics.  The  course 
which  an  individual  case  will  pursue  can  not  be  predicted  in  ad- 
vance.    It  is  natural  to  suppose  that  the  chances  are  best  where  the 


REFLEX  GASTRIC   NEUROSES.  447 

symptoms  have  been  mild,  and  vice  versa  /  but  on  this  very  point  I 
have  repeatedly  erred.  Apparently  very  severe  cases  were  cured  in 
a  relatively  short  space  of  time,  while  seemingly  simple  ones  per- 
sisted for  years.  In  general,  only  this  much  can  be  premised,  that 
at  best  the  trouble  is  one  of  long  duration,  lasting  for  months  at 
least,  and  that  the  external  appearance  of  the  patient  affords  no  clew 
to  the  severity  of  the  neurasthenic  symptoms.  I  have  frequently 
treated  young  men  who  were  the  picture  of  health,  and  whose  com- 
plaints were  therefore  ridiculed.  There  are  other  cases  in  which 
the  patients  decline  very  much,  emaciate,  and  become  so  miserable 
that  some  English  writers  have  even  described  extreme  conditions 
of  weakness,  with  terminal  oedema,  fever,  and  death. 

TV.  Reflex  Gastric  ISTeueoses  from  other  Organs. 

Under  this  heading  I  include  palpable  changes  in  organs  other 
than  the  stomach,  whose  effects  are  observed  in  the  gastric  nerves ; 
in  other  words,  those  morbid  manifestations  to  which,  like  all  other 
reflex  conditions,  the  axiom  Ablata  causa  cessit  effectus  has  a 
special  significance.  Too  frequently  is  the  cause  of  the  cases  sought, 
not  in  the  real  primary  area,  but  incorrectly  in  the  place  secondarily 
involved  ;  therefore,  a  brief  resume  of  the  reflex  symptoms  known 
to  us  may  serve  to  remind  you  what  organs  and  morbid  processes 
are  to  be  especially  considered. 

The  reflexes  manifest  themselves  as  (1)  mild  disturbances  of 
digestion  ;  (2)  gastralgias  ;  (3)  vomiting  ;  the  latter  occurs  especially 
in  acute  affections,  the  former  in  those  whose  nature  is  more  chronic. 
But  just  as  these  three  types  may  very  frequently  be  interchange- 
able, and  even  occur  in  combination,  so  may  chronic  processes  give 
rise  to  the  symptoms  of  an  acute  gastric  disorder,  if  they  exacerbate 
suddenly  or  involve  specially  predisposed  nervous  plexuses,  etc.,  in 
their  course.  This  is  well  shown,  for  example,  in  the  crises  of  loco- 
motor ataxia. 

The  fact  has  been  repeatedly  mentioned  that  the  stomach  is  the 
center  of  a  nervous  plexus  whose  branches  have  very  wide  connec- 
tions, and  directly  or  indirectly  involve  nearly  every  organ  in  the 
body ;  hence,  an  irritation  which  is  manifested  at  any  point  in  this 
plexus  will  reach  the  stomach,  just  as  in  any  peripheral  end-appa- 


448  DISEASES  OF  THE  STOMACH. 

ratus.  Of  especial  importance  are  the  reflexes  from  the  central 
nervous  system,  the  great  glandular  organs  in  the  abdomen,  the  in- 
testines, genital  tract,  and,  finally,  the  heart  and  lungs. 

The  cerebral  disorders  —  meningitis,  hsemorrhages,  abscesses, 
tumors — are  usually  accompanied  by  vomiting  of  a  transitory  or 
more  permanent  character,  and  frequently  by  hypersecretion  of  the 
gastric  juice,  as  was  already  known  to  Andral.*  The  presence  of 
this  abundant  secretion  of  gastric  juice  during  life  will  therefore 
explain  the  rapidity  with  which  post-mortem  softening  of  the  stom- 
ach may  take  place  in  these  cases.  Vomiting  usually  occurs  during 
the  course  of  the  disease,  or  it  may  usher  it  in  and  thus  cause  great 
misconceptions,  as  is  well  known  in  meningeal  inflammation,  espe- 
cially of  children,  and  in  tumors.  Therefore,  every  case  of  long 
standing,  or  even  unyielding  vomiting,  must  be  considered  from 
this  standpoint.  The  vomiting  of  sea-sickness,  migraine,  and  the 
beginning  of  psychical  affections,  may  also  be  included  in  this  vari- 
ety of  reflex  vomiting.  Of  the  latter  occurrence  I  have  two  exam- 
ples in  which,  apparently  from  a  gastric  catarrh,  very  obstinate 
vomiting  was  developed,  which,  after  having  lasted  several  weeks, 
was  followed  by  a  psychosis.  Lesions  in  the  cervical  and  dorsal 
portions  of  the  spinal  cord  cause  gastralgia,  sometimes  with  vomit- 
ing, as  soon  as  the  centers  or  nerve-roots  concerned  are  involved. 
Such  "  gastric  crises  "  occur  not  alone  in  the  gray  degeneration  of 
the  posterior  columns  (tabes),  but  also  in  insular  lesions  of  dissemi- 
nated sclerosis.  Vomiting  is  also  of  frequent  occurrence  in  ab- 
scesses and  calculi  in  the  liver  and  kidneys,  especially  when  they 
pass  into  the  excretory  ducts  and  thus  irritate  their  sensory  nerves. 

I  will  recall  the  vomiting  of  pregnancy  not  alone  to  indicate  a 
very  common  reflex  upon  the  stomach,  but  also  a  not  infrequent 
source  of  diagnostic  doubts  and  errors.  How  frequently  has  ap- 
parently serious  vomiting,  which  simulated  some  grave  disorder  of 
the  stomach,  simply  proved  to  be  the  first  manifestation  of  a  preg- 
nancy !  It  occurs  in  the  early  part  of  gestation,  while  the  uterus  is 
still  in  the  pelvis,  since  this  variety  of  vomiting  is  due  to  the  press- 
ure of  the  enlarged  womb  upon  the  sympathetic  nerves.     The  dis- 

*  Quoted  by  Budd,  loc.  cit. 


REFLEX  GASTRIC  NEUROSES.  449 

order  may  reach  sucli  a  degree  that  all  remedies  are  useless,  if  the 
uterus  is  unusually  large  or  is  misshapen,  or  if  its  muscular  fibers 
are  inflamed,  or  if  it  is  misplaced.  But  acute  injuries  or  maltreat- 
ment of  this  organ  may  also  cause  vomiting — e.  g.,  snaring  a  polyp 
at  the  fundus  uteri  preparatory  to  its  removal.  Dr.  Daumann  had 
such  a  case  in  which  pain  and  vomiting  set  in  every  time  the  loop 
was  tightened,  while  the  latter  ceased  as  soon  as  the  ligature  was 
loosened.  The  same  thing  has  been  observed  in  operations  on  the 
bladder,  urethra,  etc. 

Chronic  disorders  of  the  female  as  well  as  of  the  male  sexual 
organs  may  be  followed  by  chronic  dyspeptic  conditions.  I  would 
here  remind  you  that  the  normal  process  of  menstruation  causes 
retardation  of  gastric  digestion,  or  even  complete  absence  of  free 
hydrochloric  acid  in  the  stomach-contents,  as  was  first  demonstrated 
by  Kretschy,""  and  later  confirmed  by  Fleischer, f  and  Boas  and 
myself. :{:  How  much  greater  reflexes  will  be  referred  to  the  stom- 
ach and  intestines  by  amenorrhoea  and  dysmenorrhoea,  the  climac- 
teric period  and  chronic  disorders  of  uterus  which  are  associated 
with  an  irritability,  or  even  with  a  direct  excitation  of  its  nerves ! 
Hence  we  can  understand  why  Ivisch*  found  "  dyspepsia  uterina" 
most  frequently  in  retroflexion  of  the  enlarged  uterus,  then  in  mal- 
positions in  general,  myomata,  pelvic  exudations  with  traction  on 
the  uterus  and  its  adnexa,  follicular  or  carcinomatous  ulcers  of  the 
cervix,  and  ovai'ian  tumors ;  but  it  was  absent  in  simple  and  mild 
endometritis,  chronic  catarrhs,  and  small  perimetric  and  parametric 
exudations.  Such  dyspeptic  conditions  which  may  have  persisted 
for  years  have  been  cured  in  a  surprisingly  short  time  by  appro- 
priate local  treatment. 

I  have  recently  observed  a  peculiar  and  rare  example  of  a  reflex  of  this 
kind  which  first  involved  the  salivary  glands  and  indirectly  the  stomach — 
i.  e.,  sialorrhoea  with  dyspepsia  resulting"  therefrom.  An  unmarried  lady, 
foi^ty-one  years  of  age,  was  said  by  her  physician  to  have  suffered  for  two 

*  F.  Kretsehy.  Beobaehtungen  iind  Versuche  an  einer  Magenfistelkraiiken. 
Deutsches  Archiv  fur  klin.  Med.^  Bd.  18,  S.  257. 

f  E.  Fleischer.  Ueber  die  Verdauungsvorgange  im  Magen  unter  verschiedenen 
Einfliissen.     Berl.  klin.  Wochenschr.,  1882,  No.  7. 

X  Ewald  und  Boas.  Zur  Physiologie  und  Pathologie  der  Verdauung.  Vir- 
chow's  Archiv,  Bd.  104. 

*  H.  Kisch.     Dyspepsia  uterina.     Berl.  klin.  Wochenschr.,  1883,  No.  18. 


450  DISEASES  OP  THE  STOMACH. 

and  a  half  months  from  loss  of  appetite,  bitter  taste  in  the  mouth,  consti- 
pation, feeling  of  oppression  over  the  stomach,  and  for  several  weeks 
very  severe  salivation.  She  was  much  emaciated,  felt  very  weak,  and 
had  the  greatest  repugnance  toward  exerting  herself,  although  she  was 
formerly  very  active.  She  lived  upon  her  estate,  and  had  already  taken 
Carlsbad  water,  condurango,  nitrate  of  silver,  and  small  doses  of  quinine ; 
cold  rubbings  and  suitable  diet  had  also  been  tried,  but  all  without  suc- 
cess. On  the  patient's  admission  to  the  sanitarium  the  amount  of  saliva 
secreted  daily  was  found  to  be  about  two  litres  [4^  pints] ;  this  was  exam- 
ined in  Prof.  Kossel's  laboratory  and  found  normal.  No  great  changes 
discovered  in  the  gastric  chemical  functions ;  acidity  48.  No  other  anom- 
alies found ;  the  mouth  was  free  from  any  special  disease.  Every  kind  of 
poisoning  by  the  coating  of  mirrors,  mouth-washes,  hair-dyes,  and  the 
like,  was  excluded.  After  a  fortnight's  trial  of  pills  of  atropine,  and  hy- 
podermic injections  of  morphine  and  atropine,  with  only  temporary  effect 
on  the  symptoms,  I  discovered  a  retroflexion  of  the  uterus.  With  the 
introduction  of  a  pessary  the  obstinate  ptyalism  and  the  dyspeptic  con- 
dition very  soon  disappeared. 

In  conclusion,  I  must  mention  the  reflexes  from  the  intestines, 
such  as  are  caused  bj  worms,  enteroliths,  and  neoplasms  in  and 
about  the  gut.  The  parasites,  especially,  play  an  important  part 
here.  I  shall  not  go  into  details  about  the  serious  disturbances  of 
nutrition  which  may  be  caused  by  the  distoma  and  strongylus  varie- 
ties, neither  shall  I  speak  of  the  disease  of  tunnel  workmen  and 
brick-burners.*  It  will  suffice  to  mention  the  ordinary  ascarides 
and  taenia,  and  recall  the  fact  that  many  a  long-standing  "  nervous 
dyspepsia  "  has  been  terminated  by  the  expulsion  of  a  tape-worm  ! 

Treatment  of  the  Leukoses  of  the  Stomach. 

In  all  the  nervous  diseases  of  the  stomach  the  treatment  will 
depend  upon  the  question  whether  they  are  of  an  irritative  or  de- 
pressive nature. 

The  conditions  of  increased  irritability  must  be  separated  into 
those  in  which  the  hypersesthesia  is  local  and  those  which  are  cen- 
tral in  origin. 

For  local  hyj)er?esthesia,  opium  and  its  derivatives — morphine, 
codeine,  and  narceine — have  been  invaluable  for  ages.  In  general, 
morphine  is  best  administered  in  watery  solution,  or  in  bitter-almond 

*  [The  Tunnelkranhheit  or  Bergkachexie  is  a  form  of  anaemia  caused  by  the 
anchylostomum  duodenale.  It  has  also  been  called  Gothard-Tunnel  disease.  The 
same  parasite  is  the  cause  of  brick-burner's  anaemia. — Tr.] 


TREATMENT  OP  THE  GASTRIC  NEUROSES.  45 1 

water,  since  it  is  not  dissolved  in  tlie  stomach  if  given  in  substance, 
or  has  little  or  no  action.  The  most  rapid  effects  may  be  obtained  by 
hypodermic  injection  in  loco  affecto  /  I  usually  follow  the  English 
custom  of  adding  one  tenth  part  of  sulphate  of  atropine,  partly  to 
counteract  any  possible  nauseating  effects  of  the  morphine,  partly  to 
obtain  the  relaxing  effects  of  the  atropine.  This  is  an  excellent 
combination,  which  may  be  very  useful  in  patients  who  have  inva- 
riably had  nausea  and  vomiting  after  the  simple  morphine  solution. 
For  example,  in  bulimia,  Eosenbach  has  recommended  the  hypoder- 
mic use  of  extract,  opii  which  has  been  dissolved  in  glycerin,  filtered 
and  diluted  with  water ;  but  I  have  had  no  occasion  to  use  it.  If 
the  general  sedative  effect  on  the  entire  nervous  system  is  desired, 
and  if  there  are  reasons  why  it  should  not  be  given  by  the  mouth, 
or  subcutaneously,  it  may  be  administered  in  suppositories  of  0*03 
to  0*05  !  [gr.  -I  to  f]  each,  or  O'l  to  0-15  !  [gr.  j|-  to  iji]  per  day.  The 
action  of  opium  and  morphine  may  be  assisted  by  hydrocyanic  acid, 
in  small  doses,  in  the  form  of  aqua  amygdalae  amarse.  Hydrochlo- 
rate  of  cocaine  may  be  unhesitatingly  given  internally,  in  doses  of 
0'05  to  0"1  gramme  [gr.  |-  to  jss.]  ;  yet  one  must  not  forget  that,  in 
some  individuals,  even  the  first  dose  may  be  followed  by  unpleasant 
symptoms  of  irritation — sleeplessness,  restlessness,  pulsation  of  the 
arteries,  and  oppression  and  pain  in  the  head.  For  prolonged  use 
and  wliere  the  symptoms  are  mild,  coca  wine  may  sometimes  be 
valuable.  As  an  antispasmodic  we  may  use  the  preparations  of 
belladonna,  either  pills  of  extract  of  belladonna  or  atropine,  or  the 
tincture. 

In  hysterical  hypersesthesise,  gastralgias,  vomiting,  and  even  in 
spasmodic  conditions,  I  have  been  very  well  satisfied  with  the  fol- 
lowing combination  of  tlie  remedies  mentioned  above  : 

'^  Morphinse  hydrochloratis . .      0'2  [gr.  iij] 

CocainaB  hydrochloratis .  . . .      0*3-0*5      [gr.  ivss.-vijss.] 

Tincturse  belladonnge 5-0-10-0    [f3j|-ijss.] 

AquEe amygdalae amar^e.  .. .    25*0  [-fS^ji] 

M.     Sig. :  Ten  to  fifteen  drops  every  hour. 
However  indispensable  morphine  may  be,  the  fact  of  its  subcu- 
taneous use  being  a  two-edged  sword  in  all  chronic  forms  of  disease 

is  well  known ;  and  it  is  just  in  neuroses  now  under  discussion  that 
29 


452  DISEASES  OP   THE  STOMACH. 

both  physician  and  patient  should  always  keep  before  their  eyes  the 
terrible  dangers  of  the  morphine  habit. 

This  need  not  be  feared  with  chloral  in  3  to  5  per  cent  solution, 
sometimes  in  combination  with  cocaine,  to  be  taken  at  one  and  one 
half  to  two  hours'  intervals  ;  it  has  a  good  sedative  action.  Sulphonal 
is  an  excellent  hypnotic,  but  unfortunately  it  has  absolutely  no  effect 
on  the  dyspeptic  disturbances.  Furthermore,  it  must  not  be  for- 
gotten that,  although  it  is  usually  well  borne,  yet  in  some  persons 
even  small  doses  of  two  to  three  grammes  [gr.  xxx-xlv]  may  be  fol- 
lowed by  severe  toxic  symptoms.  The  feeblest  and  not  always  re- 
liable analgesics  are  the  preparations  of  bismuth,  either  alone  or  in 
combination  with  morphine  or  extract  of  hyoscyamus  or — in  mild 
cases,  and  especially  in  children — rhubarb.  Swallowing  small  pieces 
of  cracked  ice  with  three  to  five  drops  of  chloroform,  may  be  recom- 
mended for  rapidly  allaying  pain ;  the  same  is  true  of  chloroform- 
water,  which  may  be  prepared  by  shaking  water  with  an  excess  of 
chloroform,  decanting  and  diluting  with  half  the  quantity  of  an 
aromatic  water ;  the  dose  is  a  teaspoonful  at  intervals  during  the 
day. 

Rosenthal,  Leube,  Yizioli,  and  Rosenbach  have  repeatedly  ob- 
served the  lessening  and  even  disappearance  of  gastralgias  by  the 
anodal  action  of  the  constant  current.  A  sedative  effect  is  also 
claimed  for  the  continuous  use  of  the  "  galvanic  chain  "  (zinc  [neg- 
ative] pole  on  the  lumbar  portion  of  the  spinal  column,  the  silver 
[positive]  pole  upon  the  stomach).* 

Surprising  results  may  sometimes  be  obtained  by  local  treatment 
with  the  internal  stomach-douche,  which  was  first  recommended  by 
Malbranc  f  (Prof.  Kussmaul's  clinic)  (see  p.  63).  This  massage  of 
the  stomach  seems  to  exert  a  quieting  influence  on  the  hypersensi- 
tive gastric  nerves,  just  as  ordinary  massage  often  unexpectedly  re- 
lieves painful  neuroses.  Malbranc  has  formulated  Kussmaul's  ex- 
perience and  opinion  in  explanation  of  the  beneficial  effects  of  the 


*  [Good  results  have  also  been  claimed  after  intraventricular  galvanization,  the 
negative  pole  being  in  the  stomach  and  the  positive  over  the  epigastrium. — Tr.] 

f  M.  Malbranc.  Ueber  Behandlung  von  Gastralgien  mit  tier  inneren  Magen- 
douche  nebst  Bemerkungen  iiber  die  Technik  der  Sondirung  des  Magens.  Berl. 
klin.  Wochenschr.,  1876,  S.  41. 


TREATMENT   OP  THE   GASTRIC  NEUROSES.  453 

stomach-douche  in  the  following  conclusions,  although  in  the  case 
quoted  below  only  the  last  mentioned  are  concerned :  (1)  Removal 
of  stagnant  remnants  of  food  from  the  stomach ;  (2)  relief  from 
acid,  acrid  masses  (products  of  decomposition)  and  mucus ;  (3)  the 
quieting  effect  of  the  warm  water  bath  ;  (4)  stimulation  of  the  peri- 
stalsis by  the  impact  of  the  stream  of  water ;  (5)  the  mildly  anaes- 
thetic as  well  as  the  stimulating  effects  on  the  muscular  fibers  of  the 
stomach  from  the  carbonic-acid  gas  ;  (6)  the  increase  in  the  peri- 
stalsis of  the  intestines  by  the  last  two  factors. 

As  an  example  of  the  beneficial  effects  of  the  douche  I  wish  to 
describe  the  following  case  which  I  presented  at  my  lecture  on  Oc- 
tober Y,  188 7  : 

A  married  woman,  thirty-six  years  old,  the  mother  of  one  child,  came 
ten  days  before,  complaining-  of  intense  gastralgia,  complete  loss  of  appe- 
tite, and  great  lassitude.  She  was  of  a  slight  build  and  her  appearance 
was  bad ;  her  eyes  especially  were  dull  and  languid,  as  they  are  after 
sleepless  nights.  Her  illness  began  five  months  previously  with  cramps 
in  the  stomach.  For  the  preceding  eight  weeks  the  attacks  had  occurred 
several  times  a  day ;  sometimes  they  were  almost  uninterrupted  and  were 
present  at  night  quite  independently  of  eating.  Nothing'  abnormal  was 
found  in  the  stomach  and  abdomen  ;  heart  and  lungs  were  normal. 
While  fasting,  about  30  c.  c.  [  |  j]  of  a  neutral  turbid  yellow  liquid,  which 
was  not  slimy,  were  exj)ressed  from  the  stomach.  This  was  undoubtedly 
regurgitated  fluid  from  the  duodenum.  After  the  test-breakfast  the  acid- 
ity was  very  feeble,  with  only  a  trace  of  hydrochloric  acid.  She  had  a  large 
batch  of  prescriptions  of  various  narcotics  and  sedatives  which  she  had 
taken  without  any  benefit.  The  result  of  four  douches  was  that  only 
traces  of  the  attacks  occurred  during  the  daytime  ;  the  appetite  returned, 
and  greater  quantities  of  food  were  consumed. 

A  similar  change  of  tone  in  the  nervous  apparatus  may  explain 
the  effect  of  the  introduction  of  the  stomach-tube  and  feeding 
through  it  in  severe  reflex  vomiting,  especially  in  the  vomiting  of 
pregnancy ;  many  successful  examples  may  be  found  in  English 
literature.  On  the  other  hand,  I  must  agree  with  Oser,*  that  wash- 
ing or  douching  the  stomach  has  no  permanent  effect  in  hypochon- 
driacs. They  feel  well  as  long  as  the  treatment  is  kept  np,  but  as 
soon  as  the  physician  or  the  patient  stops  it,  the  old  condition  again 
returns. 

Among  the  remedies  with  a  local  action  are  also  included  moist 

*  Oser.     Wiener  Klinik,  1875,  S.  257. 


454  DISEASES  OP  THE  STOMACH. 

compresses  upon  the  epigastrium,  either  in  the  form  of  the  simple 
Neptune's  girdle  or  sedative  cataplasms  of  chamomile,  valerian,  etc. 
Mustard  papers  or  poultices,  applications  of  tincture  of  iodine,  and 
the  faradic  brush  may  also  be  used  as  derivatives. 

The  bromides  are  the  most  important  of  the  agents  which  act 
centrally ;  we  may  use  either  the  salts  of  potassium,  sodium,  or  am- 
monium, but  the  dose  must  be  large  to  obtain  a  good  effect.  The 
limit  is  about  two  to  three  grammes  [gr.  xxx-xlv]  two  or  three 
times  a  day ;  these  doses  are  usually  well  borne,  although  some  pa- 
tients bear  even  small  doses  badly ;  the  head  is  confused,  limbs  feel 
heavy ;  the  characteristic  smell  may  be  detected  iu  the  breath,  and 
sometimes  there  is  even  incontinence  of  urine.  It  is  therefore  advis- 
able to  begin  with  small  doses ;  and  in  every  case  where  the  drug 
has  been  used  for  long  periods  it  is  wise  to  make  small  intermis- 
sions in  its  administration  for  three  to  eight  days.  Erlmeyer's  bro- 
mide water  is  also  useful  here.  Antipyrin,  phenacetin,  salicylic 
acid,  and  salol,  iu  doses  of  0*5  to  1*0  gramme  [gr.  vijss.-xv]  are 
beneficial  only  for  the  hemicrania  occurring  among  the  other  gas- 
tric symptoms ;  but  otherwise  they  have  no  direct  effect  on  the 
nervous  apparatus  of  the  stomach. 

Rosenthal  employed  pilocarpine  subcutaneously  in  the  spastic 
forms  of  vomiting,  inferring  this  use  from  the  antispasmodic  action 
of  -this  drug  in  obstinate  singultus.  From  a  similar  theoretical 
standpoint  we  may  recommend  physostigma,  the  central  paralyzing 
power  of  which  is  well  known,  and  which  was  recently  tried  by 
Riess  and  G.  Meyer.  I  have  seen  very  favorable  results  from  in- 
jections of  physostigma  in  the  spastic  incoordinated  gait  of  patients 
with  tabes ;  possibly  an  analogous  good  result  may  be  obtained  in 
gastric  crises  and  nervous  vomiting. 

I  may  also  speak  here  of  the  valerianate  and  the  natrio-sali- 
cylate  of  caffeine — in  doses  of  0"1  [gr.  jss.]  two  to  three  times  daily 
and  of  nitroglycerin,  which  Talma  valued  so  highly.  I  have  no 
personal  experience  with  the  former  except  in  the  conditions  of 
migraine,  in  which  it  is  well  known  that  all  remedies  thus  far  rec- 
ommended have  a  prompt  action  at  first,  but  are  absolutely  use- 
less sooner  or  later.  I  have  used  nitroglycerin  only  twice,  and 
in  both  cases  the  pains  in  the  head  and  the  vascular  excitation 


TREATMENT  OF  THE  GASTRIC  NEUROSES.  455 

were  so  marked  that  I  have  been  afraid  to  try  it  since.  It 
may  be  used  in  doses  of  0'5  milligramme  [gr.  j^^  in  oil  or  in 
tablets. 

In  nearly  all  of  the  conditions  under  discussion,  a  general  toning 
of  the  constitution  by  improving  the  metabolism  and  the  composi- 
tion of  the  blood  is  indicated,  as  well  as  an  excitation  or  quieting  of 
the  nervous  system.  The  preparations  of  arsenic  and  iron  are  the 
best  for  this  purpose. 

Although  I  formerly  used  Fowler's  solution  (i.  e.,  the  arsenite  of 
potassium)  most  frequently,  yet  now,  in  accordance  with  Liebreich's 
recommendation,  I  employ  arsenious  acid  almost  exclusively,  either 
in  solution : 

^r   Acidi  arseniosi 0*02  [gr.  ^] 

Aquae  menthse  piperitse 20*0  [f  3  v] 

M.     Sig. :  Ten  drops  t.  i.  d.,  and  increase. 

It  may  also  be  administered  in  granules  of  one  milligramme 
[gr.  •^],  or  in  the  form  of  Asiatic  pills  : 

[^  Acidi  arseniosi 0*75  [gr.  xj] 

Pulveris  piperis  nigri 6*0  [  3  jss.] 

Gummi  arabici 1*5  [gr.  xxiij] 

Pulveris  radicis  altheas 2'0  [gr.  xxx] 

Aquae  q.  s.  ut  fiat  pil.  no.  c. 

M.     Sig. :  One  to  three  pills  t.  i.  d.] 

If  the  precaution  be  taken  of  avoiding  any  irritation  of  arsenic 
upon  the  mucous  membrane  by  giving  it  only  when  the  stomach  is 
full,  and  if  the  above  preparations  be  employed,  then  the  drug  can 
be  used  for  a  long  time  and  in  larger  doses  than  is  usually  possible — 
i.  e.,  up  to  10  to  15  milligrammes  [gr.  -i— |-]  per  day — without  any  bad 
ejffects. 

The  mineral  waters  of  Roncegno  and  Levico  in  South  Tyrol  ai*e 
excellent  means  of  giving  iron  and  arsenic.  Even  very  weak  and 
delicate  persons  may  continue  their  use  for  a  long  time,  provided 
they  begin  with  small  doses — a  tablespoonful  once  daily,  half  an 
hour  after  the  midday  meal,  and  gradually  increase  up  to  two  to 
three  tablespoonfuls. 

Iron  is  also  usually  well  borne  when  combined  with  a  purgative. 
I  frequently  use  Dr.  Saundby's  formula :  , 


456  DISEASES  OF  THE  STOMACH. 

5^   Ferri  sulpliatis gi*-  i]  [0'12] 

Acidi  sulphuric!  diluti rrixv  [0*'75] 

Magnesii  sulpliatis g^'-  xj  [0*75] 

Aquse  menthse  piperitse §  j  [30'0] 

M.     Sig. :  Tal.  dos.  thrice  daily. 

If  we  disregard  the  iron  waters,  the  best  way  of  administering 
this  metal  is  in  combination  with  albuminates,  as  albuminate  of  iron. 
Ferruginous  preparations  are  as  abundant  as  the  sand  on  the  shore, 
and  every  form  has  found  its  panegyrist ;  but  the  preference  of  one 
above  the  other  depends  mostly  upon  individual  experience  and 
coincidences.  I  use  almost  exclusively  the  chlorine  compounds  of 
iron,  to  the  ease  of  the  absorption  of  which  I  have  repeatedly  called 
attention — i.  e.,  the  tincture  of  the  chloride  of  iron  ;  the  sesqui- 
chloride  of  iron  in  substance  (combined  with  arsenic  or  quinine  or 
chinoidin  in  pills) ;  or  liquor  ferri  sesquichlorati  (Ph.  G.)  [liquor 
ferri  chloridi,  U.  S.  P.]  mixed  together  in  2  to  5  per  cent  solution, 
and  given  in  teaspoonful  doses  with  white-of-egg  water  (1  part  of 
white  of  egg,  5  parts  water).  This  makes  an  albuminate  of  iron 
which  is  very  well  borne,  almost  without  excejition,  even  by  very 
sensitive  stomachs,  and  may  replace  the  expensive  liq.  ferri  album. 
Drees  (Ph.  Germ.).*  The  hsematogenous  remedies  may  be  com- 
bined with  the  so-called  tonics,  cinchona  bark,  and  the  other  bitters. 

The  various  hydriatic  procedures  must  be  considered  among 
those  methods  which  have  a  strengthening  as  well  as  a  soothing 
influence.  These  include  the  methodical  use  of  lukewarm  half- 
baths,  washing  the  whole  body  Math  lukewarm  sprinkling  douches 
— the  so-called    Scotch  douches  f — packing  with   tepid  water,  and 


*  [Dietterich's  liquor  ferri  peptonati  is  also  a  useful  preparation ;  it  may  be  given 
alone  or  in  combination  with  Fowler's  solution,  tinet.  nue.  vomicse,  etc.  See  also 
Goodhart,  Rest  and  Food  in  the  Treatment  of  Anaemia  and  Anorexia  Nervosa. 
Amer.  Jour.  Med.  Sciences,  September,  1891,  p.  238. — Tr.] 

f  [The  Scotch  douche  consists  of  a  stream  of  water,  about  the  size  of  a  finger, 
which  is  directed  against  the  epigastrium.  The  temperature  of  the  water  is  rapidly 
alternated,  30°  C.  (86°  F.)  and  12°  C.  (54°  F.),  every  ten  to  twelve  seconds.  It  lasts 
two  to  three  minutes,  and  may  or  may  not  be  followed  by  a  warm  pack.  The  alter- 
nation of  heat  and  cold  is  very  stimulating  to  the  entire  neuro-museular  apparatus 
of  the  digestive  tract.  At  the  same  time  it  causes  hypersemia  of  the  abdominal 
parietes  and  viscera.  Both  of  these  actions,  the  stimulating  and  the  vascular,  are 
increased  by  the  mechanical  effects  of  the  impact  of  the  stream  of  water  against 


TREATMENT   OP  THE  GASTRIC  NEUROSES.  457 

cool  sitz-batlis.  I  would  warn  against  the  nse  of  too  cold  water, 
which  frequently  has  an  exciting  and  irritating  effect ;  for  this 
reason  cold  river  and  sea  baths  may  sometimes  be  badly  borne. 
To  make  an  error  of  this  kind  in  a  feeble  and  anaemic  person  is  of 
less  importance  than  it  would  be  in  the  by  no  means  insignificant 
number  of  neurasthenics  who  apparently  have,  or  imagine  that  they 
have,  a  strong  constitution,  and  hence  believe  that  the  more  the 
cold  water  causes  them  to  shiver  the  greater  will  be  its  healing  in- 
fluence. 

In  a  certain  group  of  patients  with  nervous  stomach-troubles,  in 
whom  persistent  anorexia  has  led  to  very  profound  disturbances  of 
nutrition,  marked  emaciation,  and  enfeeblement  of  the  body,  the 
use  of  the  rest-cure  {Mast-hur)  is  to  be  recommended.  This  method, 
as  is  well  known,  was  first  introduced  by  Weir  Mitchell,  and  modi- 
fied by  Playfair,  of  London,  and  Burkart,  Leyden,  and  Binswanger, 
in  Germany ;  its  object  is  to  introduce  and  cause  the  absorption  of 
a  quantity  of  food  which  the  patient  under  ordinary  circumstances 
is  able  neither  to  take  nor  to  assimilate.  With  this  purpose,  the 
treatment  consists  of  two  parts — a  psychical  and  a  vegetative  or 
dietetic.  The  object  of  the  former  is  to  remove  the  patient  from 
the  injurious  influences  which  his  surroundings  and  his  usual  habits 
of  daily  life  exert  upon  him,  these  being  adapted  to  his  complaint; 
therefore,  he  is  kept  isolated  from  these  deleterious  factors,  so  that 
he  is  completely  under  the  control  of  his  physician,  whose  orders  he 
must  obey  even  to  the  smallest,  apparently  trivial,  details.  For  this, 
it  is  absolutely  essential  to  separate  the  patient  from  his  family  and 
keep  him  at  a  sanitarium. 

The  dietetic  measures  aim  to  overfeed  him — i,  e.,  at  least  during 
the  early  part  of  the  treatment,  to  give  more  nourishment  than  is 
required  to  satisfy  his  subjective  wants  Rest  in  bed  is  essential  to 
prevent,  as  far  as  possible,  the  conversion  of  the  food  for  heat  pro- 
duction and  muscular  work ;  but  at  the  same  time  the  circulation  is 
improved  by  passive  muscular  exercise  through  massage  and  elec- 
tricity. 

the  skin.  Thus,  it  is  a  powerful  adjuvant  to  electricity  and  massage  of  the  abdo- 
men. Ziemssen,  Klinische  Vortrage,  No.  xii,  1888.  Also,  see  foot-note,  p.  157. — 
Tr.] 


4:68  DISEASES  OF  THE  STOMACH. 

The  treatment  is  carried  out  as  follows  :  The  first  step  is  to  iso- 
late the  patient  and  place  him  in  charge  of  a  male  or  female  nurse, 
whose  duty  it  shall  be  to  manage  the  feeding  and  the  above-men- 
tioned mechanical  procedures ;  the  nurse  ought  also  to  have  the 
pleasant  quality  of  not  being  personally  unsym23athetic  to  the  pa- 
tient. For  the  first  few  days  the  cure  consists  in  giving  milk  in 
small  quantities  at  two  or  three  hours'  intervals,  so  that  one  or  two 
litres  [quarts]  are  taken  daily  ;  the  milk  may  be  raw  or  cooked, 
skimmed  or  fresh  from  the  cow,  warm  or  cold,  and  may  have  vari- 
ous additions  according  to  the  caprice  and  taste  of  the  patient. 
After  three  or  four  days  the  food  is  made  more  substantial  and  is 
given  in  small  amounts  every  two  hours.  This  consists  of  milk, 
meat,  farinaceous  food,  butter,  and  cofiee  or  tea ;  the  daily  quantity 
should  be  about  2f  litres  [six  pints]  of  milk,  420  grammes  [  ^  xiv]  of 
meat,  about  150  grammes  [  3  v]  of  vegetables  or  stewed  fruit,  and 
the  equivalent  amount  of  wheat  bread,  toast,  and  butter.  If  the 
stomach  rebels  against  this  rigorous  diet  and  reacts  with  an  acute 
gastric  catarrh — i.  e.,  dry,  coated  tongue,  belching,  heart-burn,  pains 
in  the  stomach  and  head — then  it  must  be  suspended  for  a  few  days. 
Great  attention  must  also  be  paid  to  the  regulation  of  the  stools. 

In  favorable  cases  improvement  is  shown  as  early  as  the  second 
or  third  week.  After  the  third  or  fourth  week  the  patients  may 
leave  the  bed,  and  may  attempt  to  walk.  Corresponding  to  the 
progressive  improvement  the  massage  and  faradization  are  gradually 
lessened  till  they  may  be  stopped  entirely.  If  no  improvement  has 
been  manifested  by  this  time,  it  is  advisable  to  refrain  from  carrying 
this  treatment  on  any  further. 

Burkart  has  suggested  that  the  cure  should  not  be  tried,  or,  at  all 
events,  should  be  carried  out  with  very  great  care  in  those  patients 
in  whom  there  are  conditions  of  cerebral  excitement,  and  especially 
where  the  disturbances  of  the  psychical  functions  are  very  pro- 
nounced. The  best  results  are  obtained  in  severe  cases  of  hysteria 
and  neurasthenia,  in  which  the  activity  of  the  digestive  organs  is  es- 
pecially involved,  and  associated  wath  this  a  marked  change  in  the 
consumption  of  food.  It  is  just  these  extremely  emaciated,  feeble 
patients  who  are  pining  away  so  wretchedly,  who  have  the  very  best 
chances  from  this  method  of  treatment. 


TREATMENT  OP  THE  GASTRIC  NEUROSES.  459 

"  I  never  saw  a  more  rapid  restoration  of  the  normal  functions 
of  digestion,"  says  Burkart,  "  than  in  those  digestive  disturbances 
occasionally  found  in  extremely  emaciated  hysterical  subjects,  and 
vi^hich  stand  in  some  close  relation  to  the  abnormal  psychical  con- 
dition." It  makes  a  wonderful  impression  if  one  has  the  oppor- 
tunity of  seeing  such  cases  in  which  the  digestive  organs  had  pre- 
viously reacted  very  unsatisfactorily  to  nourishment,  and  apparently 
could  only  take  and  digest  very  small  quantities,  when,  suddenly, 
after  a  few  days  of  the  Weir  Mitchell  regimen,  immense  amounts  of 
food  can  be  consumed  without  any  great  difficulty,  and  sometimes 
just  those  articles  whicli  have  caused  the  most  trouble  can  be  taken 
without  the  slightest  complaint.  This  gives  a  most  striking  demon- 
stration of  the  real  nature  of  the  functional  disturbances  in  which, 
unlike  organic  diseases  due  to  demonstrable  pathological  tissue- 
changes,  the  return  to  the  normal  functional  activity  may  be  accom- 
plished in  a  very  brief  time.  Where  patients  with  neurasthenia 
gastrica  have  been  successfully  treated  with  the  Weir  Mitchell  cure, 
the  normal  conditions  are  restored  much  more  slowly  than  in  hys- 
terical digestive  disorders. 

During  the  past  few  years  I  have  had  quite  a  large  experience 
in  this  method,  at  least  not  strictly  carried  out  as  proposed  by  Weir 
Mitchell,  but  in  a  milder  and  somewhat  modified  form.  The  former 
I  have  used  very  seldom,  because  I  have  rarely  found  myself  in  such 
a  position  that  I  considered  it  absolutely  necessary,  on  account  of 
the  great  expense  to  the  patient,  and  also,  as  stated  by  Burkart  and 
Leyden,  because  patients  are  sometimes  unwilling  to  be  taken  from 
their  homes.  However,  in  one  case  I  not  alone  carried  out  the  treat- 
ment to  the  smallest  details,  but  also  made  exact  investigations  of  the 
metabolism.  The  result  was  brilliant.  The  case  was  one  of  hysterical 
anorexia  in  a  girl,  sixteen  years  old,  which  had  developed  after  an  at- 
tack of  scarlet  fever  eight  years  previously.  The  patient  was  ema- 
ciated to  a  skeleton,  and  suffered  from  headaches,  tinnitus  aurium, 
color-blindness,  and  photophobia,  which  was  so  intense  that  she  had 
to  sit  in  the  dark,  and  was  unable  to  read  a  line ;  great  lassitude  and 
trembling  after  every  exertion ;  incontinence  of  feeces.  At  the  be- 
ginning of  the  treatment  she  weighed  25*6  kilogrammes  [56'3 
pounds]  ;  the  conversion  of  nitrogen  as  calculated  for  albumen  was 


460  DISEASES  OF  THE  STOMACH. 

37'19  grammes  [5Y3'84  grains].  At  first  she  received  as  food  114:'4:2 
grammes  [1765'50  grains]  of  albmnen,  which  was  gradually  in- 
creased in  four  weeks  to  195*7Y  grammes  [3020'72  grains].  She 
was  kept  isolated  from  December  5th  to  January  26th  ;  on  that  day 
the  conversion  of  albumen  was  121*06  grammes  [1914-24  grains] — 
i.  e.,  a  gain  of  71'7l  grammes  [1106"48  grains],  and  her  weight  was 
33*05  kilogrammes  [72*T  pounds] — i.  e.,  an  increase  of  Y'45  kilo- 
grammes [16'4  pounds].  I  have  had  the  opportunity  of  watching 
the  patient  three  months  longer ;  she  is  with  her  nurse  at  the  house 
of  her  parents,  gains  steadily  in  weight,  eats  well,  goes  out  walking, 
and  is  free  from  her  old  symptoms !  This  splendid  result  was  ob- 
tained only  because  during  the  entire  course  of  treatment  she  was 
free  from  all  kinds  of  gastric  and  intestinal  disturbances,  except 
those  of  a  very  slight  and  transient  nature. 

However,  it  seems  to  me  as  if  we  could  derive  as  much  benefit 
from  a  modified  course  of  treatment  in  which  the  patient  is  not  iso- 
lated, provided  he  has  a  good  nurse,  as  we  could  expect  from  a  strict 
observance  of  the  Weir  Mitchell  cure.  The  important  factors  which 
have  already  been  mentioned  above,  and  which  have  also  been  empha- 
sized in  the  various  publications  of  Burkart  (who  has  undoubtedly 
had  the  largest  experience  in  this  field  of  any  one  in  Germany),  are 
the  psychical  efi^ect  on  the  patient  and  the  latter's  firm  determina- 
tion, or  at  least  his  consent,  in  favor  of  the  proposed  treatment.  If 
both  of  these  are  present,  we  may  dispense  with  isolation  in  a  hos- 
pital, which  above  all  has  a  psychical  effect,  provided  the  patient's 
family  judiciously  co-operate  with  the  method.  I  have  frequently 
and  successfully  carried  out  such  cures  at  the  patients'  homes,  and 
know  that  others  have  also  done  so. 

In  connection  with  this  therapeutic  measure  I  wish  to  call  atten- 
tion once  more  to  the  importance  of  systematic  weighing  in  the 
nervous  affections  as  well  as  in  all  lesions  of  the  organs  of  absorp- 
tion. Important  criteria  for  judging  the  course  of  a  disease  and 
the  success  of  our  treatment  may  be  obtained  by  the  increase  or  loss 
shown  by  the  scales  ;  the  latter  (loss)  must  also  frequently  include  a 
stationary  condition  of  the  weight  according  to  the  axiom,  "  Stand- 
still is  retrogression."  The  only  precaution  necessary  is  not  to  be  de- 
ceived nor  influenced  by  small  and  inconstant  variations  in  the  bodily 


TEEATMENT  OP  THE  GASTRIC  NEUROSES.  461 

weight.  After  systematic  weighing  for  months  of  naked  persons 
who  have  been  kept  on  a  uniform  diet  and  surroundings,  I  am  con- 
vinced that  differences  of  1  to  1^  kilogramme  [2-|-  to  3^  pounds], 
from  one  day  to  another,  or  in  the  course  of  a  few  days,  may  be 
considered  normal  occurrences.  Even  continuous  considerable  losses 
do  not  necessarily  indicate  a  bad  prognosis,  at  least  as  long  as  the  cor- 
rect treatment  has  not  yet  been  discovered.  At  all  events,  it  is  true 
that  all  malignant  organic  structural  changes  are  also  accompanied 
by  constant  loss  of  weight,  with  possibly  small  transient  fluctuations, 
and  accordingly  always  have  an  unfavorable  significance  ;  but  nerv- 
ous dyspeptics,  neurasthenics,  patients  with  hsemorrhoids,  and  the 
like,  may  lose  15  to  20  kilogrammes  [33  to  44  pounds]  within  a  few 
months.  The  test  of  a  proper  and  successful  treatment  consists  in 
the  gradual  increase  of  the  bodily  weight  which  is  sometimes  mani- 
fested within  a  short  time  after  the  beginning  of  the  new  regimen, 
but  at  other  times  may  not  begin  till  after  a  period  of  continual  loss 
which  may  even  last  three  or  four  weeks.  Therefore,  the  scales 
play  an  important  part  in  all  kinds  of  stomach-diseases,  but  espe- 
cially in  the  neuroses,  and  ought  always  to  be  employed.  Surely 
all  should  imitate  the  proposition  made  long  ago  by  the  late  Be- 
necke,  that  every  one  should  keep  a  regular  record  of  his  weight. 
Prof.  Thomas  tried  it  practically  on  himself,  with  excellent  results 
for  regulating  his  diet.* 

Finally,  the  treatment  of  the  gastric  neuroses  should  include  the 
use  of  all  those  adjuvants  which  improve  the  general  condition 
and  the  mind  by  the  effect  of  a  change  of  climate,  the  stimulating 
and  quieting  influence  of  the  air  of  mountains  and  plains,  so- 
journ at  the  sea-shore,  the  tonic  springs  like  the  alkaline  waters 
of  Franzensbad,  Ems,  and  !Neuenaar ;  even  the  salines,  Wies- 
baden and  Kissingen  ;  the  mild  chalybeate  water  of  Elster,  Fran- 
zensbad, Pyrmont,  Rippoldsau,  and  the  like ;  and,  last  but  not 
least,  the  mud-baths.  Probably  these  are  nowhere  better  nor 
more  comfortably  prepared  than  at  Franzensbad,  where,  as  even 
Frerichs  said,  in  the  last  publication  which  came  from  his  pen, 
there   is   an   abundant  supply  of   material   for   their   preparation, 

*  See  Transactions  of  the  Naturforscherversammlung  zu  Berlin,  1887. 


4G2  DISEASES   OF  THE  STOMACH. 

wliicli,  naving  been  carried  on  for  years,  is  attended  to  with  the 
utmost  care. 

Once  more  do  I  warn  against  the  pernicious  practice  of  ordering 
nervous  patients  to  use  the  Glauber's  salt  waters,  especially  those  of 
Carlsbad  and  Marienbad,  because  these  waters  are  very  slowly  and 
imperfectly  absorbed  in  these  cases — "  they  lie  heavily  on  the  stom- 
ach," and  exert  a  decidedly  enfeebling  effect ;  the  latter  is  due  to 
the  fact  that  they  involve  still  more  the  already  altered  metabolism, 
that  they  saturate  the  blood  with  neutral  salts,  which  are  improperly 
excreted,  and  that  not  alone  do  they  not  improve  the  nutrition  of 
the  nervous  system,  but  actually  injure  it.  At  the  end  of  every 
summer  I  regularly  see  numbers  of  such  patients  who  have  returned 
from  these  springs  with  a  decided  deterioration  of  their  condition. 


LECTUEE   XIL 

THE  COKRELATION  OF  THE  DISEASES  OF  THE  STOMACH  TO  THOSE  OF 
OTHER  ORGANS.— THE  PRACTICAL  VALUE  OF  THE  MODERN  CHEMI- 
CAL   TESTS. 

Gentlemen  :  The  relations  wliich  exist  between  the  disturbances 
of  digestion  and  other  diseases,  as  I  need  scarcely  mention,  are  of 
the  greatest  importance.  There  is  hardly  any  internal  disorder 
in  which  gastro-intestinal  digestion  may  not  also  be  affected  to  a 
greater  or  less  degree  ;  or  it  may  be  associated  with  them  by  func- 
tional disturbances,  the  treatment  of  which  is  to  be  conducted  upon 
the  lines  already  laid  down.  However,  our  subject  to-day  is  not  the 
changes  which  accompany  febrile  and  afebrile,  localized  and  consti- 
tutional processes,  but  rather  those  cases  of  disease  which  depart 
from  the  ordinary  course,  in  which  the  gastric  symptoms  are  the 
earliest  manifestations,  or  which,  at  least  on  superficial  observation, 
seem  to  be  the  prominent  features  of  pathological  processes  which 
are  situated  outside  of  the  stomach.  Here  it  is  of  the  utmost  im- 
portance to  discover  the  real  cause  of  the  digestive  disturbances,  to 
distinguish  the  secondary  features  of  the  disease  from  the  primary, 
and  to  recognize  them  as  such. 

The  effect  of  diseases  of  other  organs  upon  the  stomach  and  their 
reciprocal  action  as  manifested  in  structural  changes  in  this  organ 
have  been  carefully  studied  by  W.  Fenwick.'*  But  as  these  investi- 
gations are  concerned  with  the  pathological-anatomical  changes  in 
the  stomach  rather  than  with  the  clinical  features  of  these  processes, 
I  shall  here  simply  state  that  Fenwick  calls  special  attention  to  the 
relation  between  advanced  atrophy  of  the  gastric  mucosa  and  perni- 


*  W.  Fenwick.    Ueber  den  Zusammenhang  einiger  krankhafter  Zustande  des 
Magens  mit  anderen  Organerkrankungen.  Virchow's  Archiv,  1889,  Bd.  cxviii,  S.  187. 

(463J 


46i  DISEASES  OP  THE  STOMACH. 

cioiis  ansemia,  and  also  of  carcinomatous  tumors  of  other  organs,  es- 
pecially the  mammary  gland  and  intestines ;  as,  for  example,  the 
occurrence  of  severe  ansemia  after  the  excision  of  relatively  insig- 
nificant tumors  of  the  breast.*  However,  as  I  have  already  shown 
in  Lecture  YIII  [page  334],  Henry  and  Osier  f  and  other  writers 
have  already  called  attention  to  this  fact. 

W.  Fenwick  also  found  more  or  less  marked  catarrh  of  the 
mucous  membrane  of  the  stomach  in  nearly  all  the  diseases  which 
were  studied  by  him — i.  e.,  diseases  of  the  kidney,  pulmonary  phthi- 
sis, chronic  bronchitis,  emphysema,  various  valvular  lesions  of  the 
heart ;  it  was  least  marked  in  acute  pneumonia  and  typhoid  fever ; 
and  not  at  all  in  diseases  of  the  brain  (tumor,  e23ilepsy,  softening, 
apoplexy).  He  also  states  that  Handheld  Jones,:}:  in  a  study  of  over 
100  cases  of  "  affections  of  the  glands  of  the  stomach,"  only  once 
found  disease  of  the  brain.  If,  therefore,  the  gastric  symptoms, 
and  especially  vomiting,  which  occur  in  diseases  of  the  central  nerv- 
ous system,  are  manifestly  reflex  nervous  symptoms,  then  the  dis- 
turbances of  the  digestive  tract  which  occur  in  other  disorders  must 
undoubtedly  depend  upon  anatomical  and  functional  changes.  The 
most  important  of  the  latter  will  now  occupy  our  attention. 

The  most  prominent  place  in  the  consideration  of  this  subject  is 
occupied  by  tuberculosis,  which  indeed  most  frequently  gives  rise  to 
errors.  It  is  only  too  well  known  that  the  course  of  phthisis  may 
be  marked  by  dyspeptic  symptoms  which  may  vary  from  a  simple 
loss  of  appetite  to  severe  anorexia  and  vomiting,  and  may  go  hand 
in  hand  with  the  febrile  movement.  But,  as  Louis,  Andral,  and 
Bourdon  pointed  out  long  ago,  there  are  many  cases  of  tuberculosis 
in  which  the  first  symptom  to  attract  attention  is  dyspepsia. 

Hutchinson  *  has  analyzed  a  large  number  of  cases  and  calcu- 
lated that  in  33  per  cent  dyspeptic  symptoms  precede  the  onset  of 
the  tubercular  manifestations.  W.  Fenwick  found  well-marked  evi- 
dences of  gastric  catarrh  in  eleven  out  of  fifteen  cases  of  phthisis — 

*  Samuel  Fenwick.     Atrophy  of  the  Stomach.     London,  1880,  p.  49. 

f  Henry  and  Osier.     Atrophy  of  the  Stomach  with  the  Clinical  Features  of  Pro- 
gressive Pernicious  Anaemia.    American  Journ.  of  Med.  Sciences,  April,  1886. 
:j:  Handfield  Jones.     Diseases  of  the  Stomach. 

*  Hutchinson.     The  Morbid  States  of  the  Stomach  and  Duodenum.     London, 
1878. 


TUBERCULOSIS.  465 

i.  e.,  T3  per  cent.  Marfan*  considers  this  figure  too  high,  and 
quotes  the  well-known  and  universally  accepted  observation  of 
Quenu  that  many  patients  disregard  the  period  of  short,  dry  cough 
which  precedes  the  onset  of  expectoration,  so  that  the  beginning  of 
the  disease  mnst  be  placed  at  an  earlier  period  than  is  given  by 
them.  In  61  cases  he  claims  to  have  found  only  five  in  which  the 
gastric  preceded  the  pulmonary  symptoms.  Yet  the  point  at  issue 
is  not  so  much  these  objections  to  the  patient's  previous  history  as 
the  fact  that  persons  frequently  consult  us  complaining  only  about 
their  digestion,  which  they  consider  the  cause  of  all  their  troubles ; 
yet  careful  examination  will  either  reveal  the  presence  of  a  phthisi- 
cal process,  or  will  cause  us  to  entertain  suspicions  of  such  a  condi- 
tion, the  correctness  of  which  is  confirmed  by  the  subsequent  course 
of  the  malady. 

As  a  rule,  these  patients  are  delicate  and  anaemic ;  they  begin  to 
complain  of  loss  of  appetite,  oppression,  and  fullness  after  eating, 
and  irregularity  of  the  bowels  ;  they  suffer  from  regurgitation  and  a 
foul  taste  in  the  mouth  ;  they  feel  feeble  and  languid.  For  a  long 
time  they  are  treated  for  chronic  catarrhal  gastritis ;  but  both  physi- 
cian and  patient  wonder  why  all  the  apparently  rational  remedies 
are  of  no  avail ;  then  a  careful  examination  is  made,  and  chronic 
pulmonary  disease  is  either  discovered  or  at  least  strongly  sus- 
pected. A  true  dullness  is  not  present,  yet  the  apices  do  not  ex- 
pand properly,  or  the  whole  of  one  side  may  expand  somewhat 
tardily  on  inspiration  ;  the  respiratory  murmur  has  a  soft,  moist, 
interrupted  character  ;  the  movements  of  the  entire  thorax  are  not 
sufficiently  deep  ;  the  manometer  shows  that  inspiration  and  expira- 
tion are  feeble ;  expiration  is  prolonged.  Careful  questioning  will 
now  reveal  that  the  patient  has  "  hacked  "  for  a  long  time  without 
paying  any  attention  to  it ;  that  he  was  scrofulous  as  a  child ;  that 
he  perspired  very  easily,  although  there  are  no  true  night-sweats ; 
and,  finally,  that  there  is  a  hereditary  predisposition.  If  we  can 
obtain  some  of  the  sputum — which,  when  the  expectoration  is  scanty, 
the  patient  frequently  disregards  or  swallows — we  may  often  suc- 

*  B.  Marfan.      Troubles  et  lesions  gastriques  dans  la  phthisie   poulmonaire, 
Paris,  1887. 


466  DISEASES  OF  THE  STOMACH. 

ceed  in  finding  a  few  tubercle  bacilli,  and  thus  at  once  corroborate 
our  diagnosis.  Under  these  circumstances  a  diseased  condition  of 
the  stomach  is  at  all  events  present,  yet  it  is  merely  the  manifesta- 
tion of  a  venous  hypersemia  and  congestion,  which  in  its  turn  is  due 
to  the  disturbance  of  the  pulmonary  circulation. 

It  was,  therefore,  important  to  study  the  chemical  processes  of 
the  stomach  in  pulmonary  phthisis.  Some  incidental  communica- 
tions were  made  on  this  subject  by  Edinger,  and  also  by  myself  ;  yet 
systematic  examinations  were  first  made  by  C.  Rosenthal,*  Klem- 
perer,f  Schetty,:]:  O.  Brieger,*  Hildebrand,||  and  Immermann  ;  ^ 
their  results,  which  agree  tolerably  well,  are  best  expressed  in  the 
following  propositions,  formulated  by  Brieger  : 

"  In  severe  cases  of  phthisis  a  normal  condition  was  found  in 
only  16  per  cent  of  the  cases,  in  the  rest  more  or  less  marked  in- 
stifiaciency  was  found ;  in  fact,  in  9"6  per  cent  of  all  the  cases  there 
was  a  complete  absence  of  all  the  normal  products  of  secretion. 

"  In  moderately  severe  cases  the  gastric  juice  was  normal  in  only 
33  per  cent ;  in  the  remainder  its  strength  varied,  the  disturbance 
being,  as  a  rule,  well  marked ;  while  in  6-6  per  cent  the  normal 
secretory  products  were  absolutely  lacking. 

"  In  the  initial  stages  the  cases  of  normal  and  disturbed  secretion 
were  about  evenly  divided." 

Absorption  and  peristalsis  seem  to  be  impaired  to  a  degree  cor- 
responding to  the  disturbance  of  the  chemical  functions. 

It  is  self-evident  that  the  above  percentages  give  an  approximate 
and  not  an  absolute  idea  of  the  relative  frequency  of  the  conditions 
under  discussion.  A  longer  period  of  observation,  a  larger  num- 
ber of  cases,  etc.,  may  easily  change  them :  thus,  it  happened  that 
Eosenthal's  observations  at  the  Augusta  Hospital  (this  report  is 


*  C.  Rosenthal.     Ueber  das  Labferment.     Berliner  klin.  Wochenschr.,  1888, 
No.  45. 

f  Klemperer.     Ueber  die  Dyspepsie  der  Phthisiker.    Ibid.,  1889,  No.  11. 
1;.  Schetty,  loc.  cit. 

*  0.   Brieger.      Ueber  die  Functionen  des  Magens  bei  Phthisis  pulmcnum. 
Deutsche  med.  Wochenschr.,  1888,  No.  14. 

i  H.  Hildebrand.     Ibid.,  1889,  No.  15. 

^  Immermann.     Verhandlungen  des  Congresses  fiir  innere  Mediein.     Wies- 
baden, 1889. 


TUBERCULOSIS.  467 

merely  preliminary)  included  only  patients  without  free  hydrochloric 
acid ;  Hildebrand's  were  those  with  continuous  fever,  which  never 
had  free  hydrochloric  acid ;  while  Klemperer  and  Immermann  en- 
countered cases  in  which  this  acid  was  present,  and  in  some  of  them 
it  was  even  in  excess  (in  the  initial  stages  of  phthisis). 

In  testing  the  motor  functions  Immermann  found  no  marked 
changes  in  53  out  of  .5^  trials — i,  e.,  the  stomach  was  found  empty 
six  hours  after  taking  Leube's  test-meal ;  on  the  other  hand,  Klem- 
perer used  his  oil  method  (page  5Y),  and  found  a  marked  enfeeble- 
ment  of  the  motility.  Furthermore,  Immermann  states  that  lie 
found  free  hydrochloric  acid  in  38  out  of  44  trials,  even  where  the 
high  fever  and  cachexia  of  the  terminal  stages  of  phthisis  were  pres- 
ent ;  Brieger  observed  it  only  in  16  to  33  per  cent.  This  discrep- 
ancy can  be  explained  by  the  former  having  used  Jaworski's  test- 
breakfast  (the  whites  of  two  hard-boiled  eggs  and  100  c.  c.  [f  5  iij 
3  ij]  of  water),  which  is  notoriously  inadequate  for  this  purpose. 

After  careful  study,  with  reliable  methods,  Grusdew  *  and  Bern- 
stein f  also  come  to  the  conclusion  that  "  hydrochloric  acid  is  either 
absent  or  reduced  to  very  small  quantities." 

At  all  events,  the  occurrence  of  gastric  disturbances  depends  on 
what  stage  of  phthisis  may  be  present.  Thus,  Hutchinson  states 
that  in  9  cases  dyspepsia  was  found  after  the  pulmonary  symptoms 
had  begun  ;  in  10  it  appeared  at  the  same  time,  and  in  33  it  preceded 
them. 

Although  all  these  investigations  give  us  important  information, 
yet  their  value  would  have  been  greatly  enhanced  had  the  observers 
laid  more  stress  on  the  comparison  between  the  subjective  com- 
plaints and  the  results  of  the  objective  examinations.  It  is  beyond 
doubt  that  the  so-called  phthisical  dyspepsia  is  not  due  to  a  tubercu- 
lar affection  of  the  gastric  mucous  membrane,  but,  as  already  stated, 
is  only  a  complication  of  this  disease  due  to  disturbance  of  the  circu- 
lation. But  it  is  equally  certain  that  a  very  large  proportion  of  the 
successful  results  of  the  treatment  in  pulmonary  phthisis  depends 
on  the  nutrition  of  the  patient  and  the  possibility  of  maintaining  it. 

*  [Grusdew.     Wratsch,  1889,  Nos.  15,  16.     Centralblatt  fur  klin.  Med.,  1890, 
S.  92.— Tr.] 

f  Iwan  Bernstein.    Die  Dyspepsia  der  Phthisiker.    Inang.  Dissert.    Dorpat,  1889. 
80 


468  DISEASES  OP  THE   STOMACH. 

The  Frencli  metliod  of  overfeeding  {sur-alimentatioii) — the  expe- 
riences of  Dettweiler,  Peiper,  Kiihle,  Liebermeister,  Leyden,  and 
others — are  the  best  proofs  of  this.  Our  therapeutic  efforts  will 
have  a  greater  effect  and  will  be  more  certain  if  we  have  ascertained 
the  functional  activity  of  the  digestive  organs  by  means  of  a  chemi- 
cal examination  independently  of  any  of  the  patient's  subjective 
complaints.  True,  it  is  self-evident  that  the  first  object  of  treat- 
ment is  the  primary  disease,  with  the  improvement  or  cure  of  which 
the  dyspeptic  symptoms  will  disappear  ;  yet  we  must  not  lose  sight 
of  the  fact  that  the  improvement  of  the  functions  of  the  stomach 
with  the  resulting  better  state  of  nutrition  will  react  favorably 
upon  the  local  process  in  the  lungs. 

Here  it  should  be  observed  that  the  specific  stomachics  are  un- 
successful, if  not  injurious,  for  they  irritate  the  already  congested 
mucous  membrane,  and  thus  increase  the  hypersemia.  It  would  be 
much  more  advisable  to  lessen  the  irritating  effects  of  thfe  food,  as 
far  as  possible,  by  ordering  a  simple,  easily  digestible  diet,  or  by  giv- 
ing in  each  individual  case  the  drugs  which  may  seem  to  be  indi- 
cated by  the  results  of  the  examination  of  the  gastric  functions,  pro- 
vided pronounced  dyspeptic  disturbance  should  render  this  necessary. 
A  general  rule  for  these  remedies  can  not  be  given,  as  is  at  once 
evident  after  a  careful  consideration  of  the  changeable  factors  here 
concerned.  Thus,  in  a  large  number  of  examinations  on  one  patient 
at  the  Augusta  Hospital,  Eosenthal  could  never  find  free  hydro- 
chloric acid  during  the  summer,  yet  when  he  returned  to  the  hospi- 
tal in  the  winter  it  was  present  in  abundance  ;  Hildebrand  observed 
the  same  thing  during  shorter  periods.  Only  this  much  is  certain, 
that  the  subjective  complaints  of  the  patient  do  not  by  any  means 
always  correspond  to  the  results  of  the  objective  examination,  and 
that  therefore  the  former  should  be  investigated  before  they  are 
allowed  to  weigh  against  methods  of  treatment  which  (like  the  ali- 
mentation force  of  the  French)  aim  to  improve  the  general  nutrition 
by  giving  larger  quantities  of  food.  Concerning  the  milk  diet,  we 
should  remember  that  its  power  of  combining  with  acids  surely 
comes  into  play  in  the  cases  or  stages  of  hyperacidity  which  have 
been  mentioned  above. 

But,  to  return  to  the  question  under  discussion,  these  cases  of 


ANEMIA.  4(59 

pretubercular  dyspepsia — if  we  may  use  tliis  short  but  improper 
expression — may  be  readily  recognized,  provided  sufficient  care  be 
exercised.  Tlie  diagnosis  is  not  so  easy  if  tlie  dyspeptic  symptoms 
are  due  to  a  centrally  located  miliary  tuberculosis  with  slight  feb- 
rile movement.  If  this  is  associated  with  a  moderate  enlargement 
of  the  spleen,  of  recent  or  old  origin,  it  may  readily  be  mistaken  for 
typhoid  fever,  especially  the  ambulant  variety.  1  recently  saw  an 
example  of  this  in  a  gentleman  from  St.  Petersburg,  who  thought 
his  stomach  was  at  fault.  He  presented  the  group  of  symptoms 
JList  described  :  there  was  a  moderate  irregular  febrile  movement, 
with  slight  evening  exacerbations,  which  was  said  to  have  existed 
for  some  time,  since  quinine,  antipjn-ine,  and  hydrochloric  acid  had 
been  prescribed  for  him.  Inasmuch  as  he  said  that  he  had  been 
suddenly  taken  ill  some  weeks  previously  after  a  journey  in  a  fever 
district,  and  had  nevertheless  not  gone  to  bed,  but  instead  had 
attended  to  his  business,  I  naturally  thought  of  the  last  stage  of 
a  "  walking  typhoid  fever "  with  an  irregular  febrile  movement ; 
all  doubt  was  dispelled  during  about  the  fourth  week,  when  the 
symptoms  of  acute  miliary  tuberculosis  became  more  and  more 
prominent.  He  died  of  undoubted  pulmonary  tuberculosis  after 
having  been  a  few  weeks  at  Gorbersdorf. 

The  changes  in  the  digestive  tract  in  ansemia  and  chlorosis  are 
closely  allied  to  the  above.  They  undoubtedly  play  an  important 
part  which,  up  to  the  present  time,  lias  been  very  much  neglected  ; 
hence,  in  the  treatment  of  ansemia,  efforts  should  first  be  made  to 
improve  the  condition  of  the  digestive  organs,  and  then  the  compo- 
sition of  the  blood.  As  has  long  been  known,  and  as  Hayem,* 
Gluczinsky,f  Pick,  :|:  and  others  have  shown  by  direct  examination 
of  the  gastric  juice  and  the  functions  of  the  stomach,  a  true  in- 
sufficiency of  the  latter  exists.  But  some  writers,  especially  Hayem, 
go  too  far  when  they  consider  that  the  changes  in  the  stomach  and 
intestines  are  the  primary  cause.     In  my  opinion,  it  is  one-sided  to 

*  Hayem.  Des  alterations  du  ehimisme  stomacal  dans  la  chlorose.  Bulletin 
medic,  1891,  No.  87. 

f  Buzelygan  und  Gluczinsky,  Ueber  das  Verhalten  des  Magensaftes  bei  den 
verscbiedenen  Formen  der  Anaemia  und  besonders  der  Chlorose.  Internat.  klin. 
Rundschau,  1891,  No.  34. 

X  Pick.     Therapie  der  Chlorose.     Wiener  med.  Wochensch.,  1891,  No.  50. 


470  DISEASES  OF  THE  STOMACH. 

claim  that  clilorosis  can  be  cured  by  the  relief  of  these  disturbances  ; 
for  it  is  by  no  means  certain  that  these  changes  in  the  digestive 
tract  are  not  secondary,  and  can  only  be  relieved  after  the  compo- 
sition of  the  blood  has  been  improved  by  appropriate  treatment. 
The  histories  of  many  patients  attest  the  truth  of  this. 

The  next  gi-oup  of  diseases  includes  the  valvular  affections  of  the 
heart.  Here,  also,  the  nature  of  the  lesion  causes  a  venous  conges- 
tion and  the  symptoms  of  a  chronic  catarrh  of  the  stomach.  Care- 
ful examination  is  required  to  reveal  incompetency  of  the  valves, 
enlargement  of  the  heart,  latent  pericarditis,  pericardial  adhesions, 
or  chronic  myocarditis.  In  such  cases  cures  can  only  be  effected  in 
the  early  stages ;  unfortunately,  these  therapeutic  measures  usually 
afford  temporary  and  not  permanent  relief  ;  yet  sometimes,  by  using 
digitalis  and  other  members  of  this  group  for  a  short  time,  we  may 
succeed  in  completely  removing  the  catarrhal  manifestations,  and 
thus  secure  a  period  of  relative  or  absolute  relief. 

A  priori,  there  can  be  scarcely  any  doubt,  for  the  reasons  above 
given,  that  the  secretory  activity  of  the  stomach  is  lessened  as  soon 
as  compensation  is  disturbed,  not  alone  in  true  valvular  lesions,  but 
also  in  other  processes  which,  directly  or  indirectly,  cause  func- 
tional disturbances  of  the  cardiac  muscle,  Hlifler  *  thought  that  he 
had  proved  this,  since,  in  ten  cases  of  the  above  kinds,  mostly  valvu- 
lar lesions,  total  absence  of  hydrochloric  acid  and  almost  negative 
digestion  of  albumen  were  found  nine  times,  in  spite  of  the  fact  that 
most  of  tlie  patients  were  still  in  the  clinical  stage  of  complete  com- 
pensation. In  the  single  patient  (moderate  mitral  insufficiency)  in 
whom  hydrochloric  acid  was  present,  he  is  inclined  to  assume  "  hy- 
peracidity." But  concerning  this  apparently  exceptional  case  it 
may  be  stated  that  it  is  by  no  means  certain  that  congestion  of  the 
gastric  mucosa  and  its  consequences  always  occur  under  these  cir- 
cumstances, for  there  may  also  be  a  compensation  in  the  stomach. 
Therefore,  the  assumption  of  hyperacidity  seems  unnecessary  to  me 
in  the  explanation  of  this  exception. 

But  it  appears  that  insufficiency  of  the  gastric  secretion  is  not  as 


*  Hlifler.     XJeber  die  Functionen  des  Magens  bei  nerzfehlern.     Miinch.  mcd. 
Wochensehr.,  1889,  No.  33. 


RENAL  DISEASES.  47I 

constant  as  Hiifler  supposed  ;  for,  in  twenty  patients  with  heart  dis- 
ease, Adler  and  Stern  *  found  that  free  hydrochloric  acid  was  always 
present  in  sixteen,  variable  in  two,  and  always  absent  in  two  cases. 
Katurally  these  writers  are  inclined  to  believe  that  this  discrepancy 
is  due  to  the  difference  in  the  methods  employed,  for  Hiifler  gave 
Leube's  meal  in  the  morning — i.  e.,  a  very  unfavorable  time — while 
Adler  and  Stern  gave  the  test-breakfast.  However,  it  is  also  prob- 
able that  the  degree  of  compensation  is  also  of  importance  in  this 
question,  for  the  clinical  picture  alone. does  not  enable  us  to  judge 
it  properly. 

The  diseases  of  the  kidney  also  involve  the  stomach  if  the  excre- 
tory products  of  the  metabolism  are  retained  in  the  organism  early 
in  the  course  of  the  affection  ;  if  excreted  in  the  stomach  and  intes- 
tines, they  will  irritate  these  viscera.  Such  cases  are  by  no  means 
common  ;  the  vomiting  and  other  symptoms  of  disturbances  of  gas- 
tric digestion  occur  long  before  the  distinct  signs  of  dropsy  or  other 
manifestations  which  would  lead  to  the  correct  diagnosis ;  hence, 
these  cases  are  thought  to  be  independent  lesions,  whereas  they  are 
really  only  due  to  chronic  uraemia.  They  may  also  occur  without 
any  disease  of  the  renal  parenchyma  where  there  has  been  a  long- 
standing retention  of  urine  from  obstruction  of  the  urinary  passages. 
Fenwick  f  assumes  that  the  mucous  membrane  of  the  stomach  can 
excrete  certain  poisons,  including  also  urea ;  the  result  of  this  irri- 
tation is  an  acute  catarrh  of  the  gastric  glands.  Degenerative  pro- 
cesses, for  example,  fatty  degeneration  of  the  glandular  epithelium 
and  amyloid  of  the  mucosa,  may  also  occur,  as  well  as  gastritis  in  the 
true  sense  of  this  term.  Biernacki :{:  lays  stress  upon  the  retention 
of  metabolic  products  which  lessen  the  secretion  of  the  gastric  jnice 
by  means  of  nervous  influences.  He  has  actually  demonstrated  this 
in  a  number  of  cases  of  nephritis  which  were  investigated  for  this 
purpose.  Therefore,  he  agrees  with  Ewald  *  in  recommending  pep- 
tonized milk  in  these  cases.     Renal  tumors,  especially  carcinoma  of 

*  Adler  and  Stern.     Ueber  die  Magenverdauung  bei  Herzfehlern.    Berl.  Idin. 
Woehenschr.,  1889,  No.  49. 

f  Fenwick,  loc.  cit. 

X  Biernacki.    Ueber  das  Verhalten  des  Magens  bei  Nierenentziindung.    Berl. 
klin.  Woehenschr.,  1891,  Nos.  25,26. 

*  Ewald.     IX.  Congress  f  lir  innere  Medicin  zu  Wien,  1890. 


472  DISEASES  OP  THE  STOMACH. 

the  kidney,  may  for  a  long  time  cause  only  disturbances  of  diges- 
tion, anorexia,  vomiting,  and  emaciation  ;  in  fact,  in  a  case  reported 
by  Colleville,*  up  to  the  patient's  death  these  were  the  only  symp- 
toms. Finally,  without  suffering  any  changes  in  the  [renal]  secre- 
tory cajjacity,  the  kidneys  may  cause  disturbances  and  pain  in  the 
stomach  on  account  of  their  unusual  site  or  mobility ;  these  effects  of 
floating  kidneys,  etc.,  have  already  been  considered  while  discussing 
gastrectasis  and  gastralgia. 

The  liver  stands  in  such  close  relationship  to  the  stomach  that 
serious  functional  disturbances  of  the  one  are  without  exception  re- 
flected on  the  other ;  this  close  connection,  and  the  fact  that  so  many 
of  the  noxious  substances  introduced  from  without  act  on  both  vis- 
cera at  once — I  will  only  mention  alcohol — render  it  very  difficult 
to  say  which  is  affected  first.  For  example,  in  the  very  great  ma- 
jority of  cases,  cirrhosis  of  the  liver  is  accompanied  by  chronic  gas- 
tritis, yet,  even  if  we  observe  that  the  symptoms  of  a  doubtful  he- 
patic cirrhosis  have  for  a  longer  or  shorter  time  preceded  a  chronic 
gastric  catarrh,  we  are  utterly  unable  to  tell  whether  the  two  stand 
in  a  causal  relation  or  are  simply  coincident.  Nevertheless,  we 
should  never  forget  the  fact  that  many  cases  of  hepatic  cirrhosis 
for  a  long  time  run  their  course  as  chronic  gastritis,  and  that  the 
same  is  true  of  cancer  of  the  liver. 

Although  I  have  frequently  called  attention  to  the  relations  of 
the  diseases  of  the  central  nervous  system  with  those  of  the  stomach, 
yet  I  must  not  neglect  to  take  this  subject  up  once  more  at  this 
place.  On  account  of  its  great  importance,  I  shall  only  specially 
discuss  the  relation  of  the  gastric  disturbances  to  sclerosis  of  the 
posterior  columns  of  the  spinal  cord  (tabes).  This  includes  not  only 
the  classical  attacks  of  gastralgia  and  gastric  crises  [see  page  403] 
which  occur  in  cases  well  advanced  a^id  recognizable,  but  also 
vaguer  sensations — slight  boring  and  radiating  pains,  a  permanent 
feeling  of  gnawing  and  burning  in  the  stomach,  or  even  more 
marked  perceptions  which  occur  among  the  prodromata,  or  as  the 
first  symptoms  of  locomotor  ataxia,  but  which  at  the  time  in  ques- 
tion have  not  yet  acquired  any  typical  characteristics.     It  is  self-evi- 

*  Colleville.     Progr.  med.,  1883,  No.  20. 


DIABETES.— GOUT.  473 

dent  that  it  is  impossible  to  make  an  exact  diagnosis  under  such  cir- 
cumstances, and  that  even  if  the  gastralgia  continue  for  years  their 
true  origin  would  not  be  recognized.  Such  a  case  has  been  de- 
scribed by  Werner ;  *  an  induration  was  found  at  the  pylorus  in  a 
patient  who  had  been  for  a  long  time  considered  hysterical ;  gastro- 
enterostomy was  performed  for  supposed  stenosing  cicatrix  of  an 
ulcer  at  the  pylorus ;  but  it  proved  to  be  simply  a  muscular  hyper- 
trophy. As  the  operation  proved  unsuccessful,  the  ovaries  were 
subsequently  removed  (Hegar's  method) ;  nevertheless,  the  gastric 
symptoms,  which  were  chiefly  manifested  as  gastralgia,  persisted ; 
and  it  was  only  five  years  later  that  distinct  symptoms  of  tabes 
appeared,  the  existence  of  which  was  confirmed  at  the  autopsy. 
Unfortunately,  the  early  symptoms  of  tabes  do  not  readily  permit  a 
positive  diagnosis ;  thus,  for  example,  the  absence  of  the  patellar 
reflex  occurs  independently  of  this  disease  so  frequently  that  the 
simple  coincidence  of  this  symptom  and  gastralgia  in  a  suspicious 
case  would  not  justify  a  diagnosis  of  locomotor  ataxia. 

Among  the  constitutional  diseases  diabetes  gives  rise  to  errors 
most  frequently.  For  years  many  diabetics  are  considered  to  be 
suffering  from  some  stomach  trouble  until  the  urine  is  examined, 
either  accidentally  or  on  account  of  the  development  of  the  specific 
symptoms  of  emaciation,  pruritus,  polyuria,  ravenous  appetite,  den- 
tal caries,  ocular  disturbances,  [thirst,]  etc. 

In  well-developed  cases  of  diabetes,  as  shown  by  Kosensteinf 
and  Gans,:{:  the  gastric  functions  are  very  variable,  and  stand  in  no 
relation  to  the  amount  of  sugar,  acetone,  and  diacetic  acid  in  the 
urine.  Eosenstein  concludes  from  his  investigations  that  in  some 
cases  free  hydrochloric  acid  may  be  absent ;  where  this  is  temporary, 
it  is  to  be  referred  to  a  gastric  neurosis ;  but,  when  it  is  j)ermanent, 
the  cause  is  atrophy  of  the  mucosa  in  consequence  of  interstitial  in- 
flammation. 

The  relations  of  gout  to  disturbances  of  digestion  have  been 

*  Gr.  Werner.  Gastrische  Krisen  als  Initialsymptom  einer  Tabes  dorsalis.  Inaug. 
Dissert.    Berlin,  1889. 

f  Rosenstein.  Ueber  das  Verhalten  des  Magensaftes  und  des  Magens  bei  Dia- 
betes mellitus.     Berlin,  klin.  Wochenschr.,  1890,  No.  13. 

X  Edg.  Gans.  Ueber  das  Verhalten  der  Magenf  unctionen  beim  Diabetes  mellitus. 
IX.  Congress  fiir  innere  Medicin.    Wien,  1890. 


474  DISEASES  OF  THE  STOMACH. 

especially  discussed  in  English  medical  literature.  According  to 
some  writers,  there  is  a  specific  goutj  disorder  of  the  stomach  re- 
sulting from  the  uric-acid  diathesis,  or  from  contamination  with  the 
products  of  incom23lete  metabolism,  or  their  insufficient  excretion 
— i.  e.,  disturbed  retrograde  metamorphosis.  Thus,  not  long  ago, 
Burnej  Yeo  "^  claimed  that  one  of  the  prominent  manifestations  of 
this  condition  was  dyspej)sia  in  all  its  forms.  Other  authors,  like 
Brinton,  Pavy,  etc.,  do  not  recognize  a  specific  gastric  disorder,  and 
may  therefore  be  considered  to  take  a  view  more  closely  allied  to 
our  own.  The  same  is  ti'ue  of  the  rheumatic  diathesis,  which  has 
plaj^ed  quite  a  prominent  part  in  French  literature.  Although  I 
have  not  met  a  single  case  of  true  gout  with  coincident  gastric  dis- 
turbances, yet  I  have  seen  numerous  such  examples  in  chronic  artic- 
ular rheumatism,  in  which  they  were  so  marked  that  the  pains  in 
the  joints  were  comparatively  insignificant. 

Whether  there  is  any  close  connection  between  these  conditions 
I  shall  refrain  from  saying,  just  as  I  shall  do  in  the  similar  relations 
of  affections  of  the  skin  and  the  stomach,  to  which  Pidoux  f  has  paid 
particular  attention.  Finally,  I  consider  that  there  is  a  much  better 
established  as  well  as  a  more  practical  connection  between  the  digest- 
ive disturbances  and  the  various  forms  of  malaria  (i.  e.,  the  manifest 
and  especially  the  latent  forms  of  intermittent  fever)  and  typhoid 
fever,  particularly  its  ambulant  variety. 

Malarial  poisoning  may  be  manifested  as  an  intermittent  car- 
dialgia  (Leube  j^)  or  in  the  form  of  the  various  neuroses  of  the  stom- 
ach, which  will  be  characterized  by  a  certain  regularity  (Rosenthal, 
Glax  *),  and  which,  according  to  the  latter  observer,  can  be  relieved 
only  by  quinine  as  long  as  the  patient  remains  in  the  malarial  dis- 
trict. Kisch  II  in  Marienbad,  and  Glax  in  Eohitsch  [an  alkaline 
saline  spring  in  Steiermark,  Austria],  both  observed  that  it  was 
most  striking  that,  after  the  use  of  the  waters  of  these  places,  the 

*  Blimey  Yeo.     On  the  Treatment  of  the  Gouty  Constitution.     British  Med. 
Journal,  January  7  and  14,  1888. 

f  Pidoux.    Rapport  de  I'herpetisme  et  des  dyspepsies.    Union  med.,  1886,  No.  1. 
X  Leube.     Beitrage  zur  Diagnostik  der  Magenkrankheiten.    Deutsch.  Archiv 
fur  klin.  Med.,  Bd.  33. 

*  Glax.     Ueber  die  Xeurosen  des  Magens.     Vienna,  1887,  S.  206. 
11  Loc.  cit. 


THE  PRACTICAL  VALUE  OP  CHEMICAL  TESTS.  475 

neuroses  first  occurred  in  true  intermitting  attacks  and  then  finally 
disappeared  altogether.  Formerly  I  not  infrequently  had  the  oppor- 
tunity of  treating  such  cases  of  marked  intermittent  dysj^epsia. 
[These  various  manifestations  are  quite  common  in  New  York,  and 
should  always  be  borne  in  mind  in  obstinate  cases.  In  the  treat- 
ment, "Warburg's  tincture  will  be  found  to  be  especially  useful. — Tr.] 

Conclusion. — The  Practical  Value  of  the  Modern  Chemical  Tests. — 

In  the  course  of  these  lectures  I  have  always  brought  forward  the 
experiences  which  have  been  gained  by  the  new  methods  of  investi- 
gation, especially  of  the  chemical  functions  of  the  diseased  stomach, 
and  I  have  thus  been  enabled  to  combine  the  old  well-known  noso- 
logical facts  viath  the  diagnostic  and  therapeutic  results  recently 
gained.  The  task  still  remains  to  mention  what  place  is  occupied  by 
the  chemical  methods  of  investigation  in  the  individual  affections  of 
the  stomach,  and  how  far  they  warrant  drawing  sound  conclusions 
upon  the  nature  of  the  disease  under  consideration.  Do  the  stom- 
ach- and  the  test-tubes  enable  us  to  discover  specific,  characteristic 
functional  disturbances  which  belong  invariably  and  exclusively 
to  an  individual  case,  and  thus  establish  the  diagnosis  like  the 
presence  of  tubercle  bacilli  in  the  sputum  and  hyaline  casts  in  the 
urine  ?  Or,  are  they  simply  the  signs  of  a  more  general  significance 
which  have  nothing  to  do  with  a  specific  morbid  process  ?  You 
know  that  some  recent  authors  have  gone  so  far  as  to  classify  the 
diseases  of  the  stomach  into  those  with  an  increase,  diminution,  and 
absence  of  hydrochloric  acid,  and  possibly  some  of  you  may  have 
regretted  that  I  "have  not  followed  the  fashion  "  and  arranged  the 
subject-matter  from  this  standpoint.  I  have  as  remote  an  idea 
of  doing  this  as  I  would  have  of  writing  a  text-book  on  special 
pathology  in  which  the  diseases  are  classified  according  to  the 
presence  or  absence  of  dropsy,  jaundice,  albuminuria,  etc.  On  the 
contrary,  if  we  wash  to  adhere  to  facts  and  avoid  exaggerations, 
our  present  knowledge  may  be  summed  up  in  the  following  propo- 
sitions : 

There  are  two  great  groups  of  results  in  the  chemical  examina- 
tions of  the  gastric  juice  which  differ  from  the  normal :  1.  The 
untimely  occurrence  of  organic  acids.     2.  The  changes  in  the  gas- 


476  DISEASES  OP  THE  STOMACH. 

trie  juice  itself  (i.  e.,  the  secretion  of  hjdrocliloric  acid,  pepsin,  and 
rennet),  and  tlie  absorption  and  motility  of  the  organ. 

1.  The  occurrence  of  organic  acids,  especially  lactic  acid,  during  a 
stage  of  digestion  in  which  they  can  not  be  demonstrated  normally 
by  the  tests  already  known  to  you.  This  is  always  characteristic  of 
definite  pathological  conditions,  the  manifestations  of  which  are  also 
perceived  subjectively  by  the  patient.  These  acids  are  due  to  ab- 
normal processes  of  decomposition  or  fermentation,  whose  causes 
may  be  manifold  but  which  are  always  combined  with  a  morbid 
state,  provided  the  latter  expression  be  made  to  include  not  only  an 
abnormal  chemical  result,  but  also  more  or  less  well-marked  disturb- 
ances in  the  afi^ected  individual.  This  explains  the  significance  of 
the  demonstration  of  lactic  and  the  fatty  acids.  The  value  of  these 
tests  is  by  no  means  diminished  by  the  fact  that  lactic  acid  can  be 
shown  to  persist  throughout  the  entire  course  of  normal  digestion  ; 
for  the  methods  employed  are  complicated  and  not  adapted  for  gen- 
eral practice.  Exactly  the  same  relation  exists  in  diabetes,  since  the 
diagnosis  of  this  condition  by  the  detection  of  sugar  in  the  urine  is 
by  no  means  affected  because  traces  of  sugar  may  also  be  found  in  nor- 
mal urine.  ]^ow,  since  these  products  of  fermentation  are  always 
associated  with  a  prolonged  stay  of  the  ingesta  in  the  stomach,  and 
usually  with  an  absolute  or  relative  lessening  of  the  secretion  of  hy- 
drochloric acid,  a  diagnosis  may  be  ventured  in  this  direction  from 
a  knowledge  of  these  facts. 

2.  Much  more  complicated  are  the  conditions  concerning  the 
significance  of  changes  in  the  gastric  juice.  Since  the  secretion  of 
pepsin  and  rennet  goes  hand  in  hand  with  that  of  hydrochloric 
acid — excepting  trifling  variations  which  have  no  practical  meaning 
— what  is  said  of  the  latter  may  serve  as  a  statement  for  all. 

In  my  opinion,  increase  or  diminution  in  the  amount  of  the  hy- 
drochloric-acid secretion  is  a  sign  which  is  related  to  the  various 
types  of  disease  only  in  so  far  that  some  tend  to  cause  its  increase, 
while  others  its  diminution  or  even  absence  ;  but  this  depends  en- 
tirely upon  the  anatomical  or  functional  disturbances  which  accom- 
pany these  morbid  types.  Katurally,  these  cause  the  changes  in  the 
production  of  hydrochloric  acid  ;  hence  it  is  their  extent  in  the 
course  of  the  disease  -which  will  determine  how  much  the  secretion 


THE  PRACTICAL  VALUE   OP  CHEMICAL  TESTS.  477 

of  acid  will  be  affected.  At  all  events,  we  may  say  that  one  group 
will  never  canse  an  increased  secretion  of  acid — i.  e.,  all  those  forms 
in  which  an  extensive  organic  destruction  or  change  in  the  secreting 
parenchyma  has  taken  place.  So  far  as  we  know,  there  is  no  vica- 
rious increase  in  the  activity  of  the  remaining  glandular  cells.  This 
group,  therefore,  includes  carcinoma,  chronic  gastritis  and  its  se- 
queliB,  atrophy  of  the  mucous  membrane,  mucous  degeneration  of 
the  gastric  glands ;  possibly,  also,  certain  chronic  vascular  lesions — 
as,  e.  g.,  amyloid  degeneration  of  the  blood-vessels  [of  the  stomach]. 

It  is  possible,  as  some  of  ray  experiences  seem  to  indicate,  that 
further  extensive  examination  will  reveal  that  profound  anaemia, 
tuberculosis,  cardiac  diseases,  diabetes,  and  similar  morbid  |)rocesses 
may  cause  the  disappearance  of  free  hydrochloric  acid.  But,  if  we 
reverse  this  statement,  and  say  that  certain  kinds  of  disease  cause  an 
increased  secretion,  we  would  be  going  too  far. 

An  increased  secretion  is  always  functional,  a  sign  of  irritation. 
But,  as  is  well  known,  every  such  overproduction  may  cause  exactly 
the  opposite  condition  ;  I  refer  not  only  to  the  result  of  exhaustion 
following  overexcitation,  but  also  to  the  condition  of  depression 
from  the  very  beginning.  Thus  it  may  hapjDcn  that  we  sometimes 
encounter  an  absence  of  hypersecretion  in  a  condition  which  is 
usually  accompanied  by  a  strong  stimulation  of  the  secreting  ele- 
ments, as  gastric  ulcer.  A  neurosis  may  manifest  itself  at  one  time 
by  an  overproduction  of  acid  during  the  period  of  digestion  (hy- 
peracidity) ;  at  another  time  by  a  continuous  secretion  (hypersecre- 
tion). Other  cases  also  exist  in  which  there  is  such  a  diminution  in 
the  secretion  of  hydrochloric  acid  that  the  amount  is  permanently 
reduced  to  a  minimum.  As  I  know  of  no  such  case  having  yet 
been  published,  the  details  of  the  following  example  of  this  condi- 
tion may  be  interesting : 

Mr.  K.,  an  actor,  twenty-eight  years  old;  slender  figure.  Previous 
history  good ;  no  organic  diseases  can  be  discovered.  He  was  always  in 
good  health  and  lived  quietly  and  regularly.  In  the  winter  of  1884-'85  he 
had  to  play  a  very  exciting  part  several  hundred  times  in  succession  at 
one  of  the  local  [Berlin]  theatres.  He  felt  exhausted  and  languid  till  in 
the  following  summer  his  condition  became  as  follows,  to  use  his  own 
words  : 

''  It  seemed  to  me  as  if  my  entire  abdomen  was  constricted  with  a  coi'd, 


478  DISEASES  OP    THE  STOMACH. 

so  that  suddenly  I  was  attacked  with  a  feeling  of  anxiety ;  there  was  also 
oppression  which  extended  high  up  into  the  chest  and  caused  a  torment- 
ing dyspnoea.  I  could  not  take  a  long,  deep  breath,  on  account  of  the 
feeling  of  undue  fullness  in  the  abdomen.  This  condition  persisted  even 
when  I  had  eaten  nothing — e.  g.,  on  awakening  ea,r\j  in  the  morning.  I 
can  not  complain  of  any  real  pains,  yet  I  have  never  felt  i*eally  well  ever 
since.  The  pressure  in  the  abdomen  and  the  oppression  following  it  con- 
tinually remiiided  me  that  my  health  was  shattered.  Although  I  fre- 
quently had  a  good  appetite  and  relished  food,  yet  not  alone  after  eating, 
but  even  during  the  meal,  severe  disturbances  set  in,  combined  with  end- 
less belching  and  eructation,  and  great  fatigue  ;  in  the  beginning  there 
was  also  vomiting,  but  after  a  few  times  this  did  not  return.  At  times  I 
was  suddenly  seized  with  a  ravenous  appetite,  after  the  satiation  of  which 
the  above  attacks  did  not  fail  to  appear. 

"  The  family  physician's  remedies  wei'e  all  of  no  avail,  and  this  condi- 
tion persisted  till  the  winter  of  1886.  Then  the  discovery  that  I  had  a 
tape-worm  gave  me  hope  that  with  its  removal  I  would  be  cured.  But, 
alas!  even  after  that,  the  old  state  persisted,  and,  if  anything,  became 
worse.  My  arduous  duties  in  the  winter  of  1886-'87  did  not  cause  the 
trouble  to  be  less  marked.  Since  then  every  part  of  my  body  feels  very 
tired  and  languid,  and  in  spite  of  careful  rest  and  forbearance  this  has 
persisted  up  to  the  present  time.  The  pressure  from  the  distended  abdo- 
men, oppression  (frequently  also  stitches  in  the  side),  and  dyspnoea  still 
persist.  In  spite  of  this  I  still  have  an  appetite,  sometimes  a  very  large 
one  ;  I  usually  relish  food,  but  after  meals,  as  a  rule,  though  not  always, 
the  unpleasant  symptoms  make  their  appearance,  and  are  more  marked  at 
some  times  than  at  others." 

I  have  now  [1889J  treated  this  gentleman  about  three  months,  and  dur- 
ing this  time  I  have  tested  his  gastric  juice  for  hydrochloric  acid  nineteen 
times,  at  the  most  varied  intervals  after  the  test-breakfast,  and  also  after  a 
moi'e  abundant  dinner.  A  small  amount  of  free  acid  could  be  detected 
only  three  times.  Propeptone  was  always  present  in  relatively  large 
quantities,  but  the  peptone  reaction  was  only  faint,  and  the  digestive 
power  of  the  filtered  gastric  contents  was  negative,  except  in  two  tests, 
unless  hydrochloric  acid  and  pepsin  were  added.  The  rennet-action  could 
be  demonstrated  in  half  of  the  tests,  and  that,  too,  in  the  absence  of  free 
hydrochloric  acid,  but  at  the  same  time  lactic  acid  was  present  ;  at  other 
times  the  tests  for  lactic  acid  and  peptone  were  positive,  although  free 
muriatic  acid,  pepsin,  and  rennet  were  all  absent.  Lai'ge  quantities  of 
mucus  were  never  present  in  the  wash-water  except  the  first  time,  when 
the  patient  had  evidently  swallowed  large  quantities,  which  were  due  to 
the  irritation  of  the  tube.  On  the  other  hand,  on  two  occasions  I  found 
small  shreds  which  differed  from  those  usually  present  in  the  wash-water, 
by  sinking  rapidly  in  the  funnel.  They  consisted  of  the  adherent  epi- 
thelial cells  of  the  gastric  mucous  membrane  already  described  (see  Fig. 
26,  p.  317).  Although  I  consider  this  pathological,  yet  such  abrasions 
continually  occur  in  the  mucosa  of  the  stomach  as  well  as  in  other  mu- 
cous membranes,  though  they  are  usually  not  found,  since  the  acid  gas- 
tric juice  digests  them.     Strychnine  was  fii-st  given  in  small  doses  ;  then 


THE  PRACTICAL  VALUE   OF   CHEMICAL   TESTS.  479 

later  on  his  stomach  was  washed  out  and  douched  every  second  day  with 
good  results.  In  this  case  there  was  sui^ely  no  mucous  catarrh  ;  an  atro- 
phy of  the  mucosa  was  also  absent,  since  this  occurs  only  as  the  conse- 
quence ot  a  long'-standing  catarrh,  or  at  a  much  more  advanced  age. 
None  of  the  symptoms  indicate  cancer  ;  what  is,  therefore,  left  but  to 
assume  that  we  are  dealing  with  a  neurosis  ? 

Addendum. — The  subsequent  course  of  the  case  proved  the  correctness 
of  my  diagnosis.  The  patient  went  to  a  well-known  establishment  for 
nervous  diseases,  and  then  spent  a  long  time  in  Switzerland.  On  his  re- 
turn the  gastric  symptoms  had  completely  disappeared,  and  in  his  own 
eccentric  way  he  could  not  say  too  much  in  favor  of  his  cure. 

But  he  now  frequently  had  attacks  of  melancholia.  The  following 
summer  he  went  to  the  country  near  a  large  lake.  One  evening  he  left 
the  house  and  never  returned.  His  body  was  found  in  the  rushes  at  the 
border  of  the  lake  ;  he  had  evidently  committed  suicide  by  drowning. 

The  case  was  thus  a  neurosis  which  had  at  first  attacked  the  vegeta- 
tive functions,  and  finally  had  involved  the  mind. 

A  number  of  cases  which  were  examined  in  188Y  by  Dr.  "Wolff, 
of  Gothenburg,  and  myself,  at  the  Franensieclianstalt  of  Berlin,  to 
determine  the  condition  of  the  gastric  juice,  may  also  be  grouped 
in  this  category.  To  our  great  astonishment  we  found  a  permanent 
absence  of  free  hydrochloric  acid  in  a  numljer  of  persons  without 
the  slightest  stomach  complaints.  At  my  request,  Dr.  Sandberg,  of 
Marstrand,  examined  these  same  cases  again  one  year  later,  but  in 
the  majority  of  them  he  found  no  change ;  in  a  few  of  them,  how- 
ever, hydrochloric  acid  was  detected.  A  neurosis  is  out  of  the  ques- 
tion, since  there  are  no  indications  of  such  a  condition  ;  but  what 
remarkable  and  latent  disorders  can  so  profoundly  affect  the  func- 
tions of  the  stomach  ?  We  can  not  assume  the  existence  of  severe 
degenerative  processes  in  the  mucous  membrane,  since  free  hydro- 
chloric acid  could  be  occasionally  detected  in  some  of  them ;  fur- 
thermore, although  I  have  been  watching  these  cases  for  a  number 
of  years,  I  have  seen  no  gastric  symptoms  which  would  necessarily 
be  present  in  such  a  serious  condition.  After  making  similar  ob- 
servations Dr.  Grundzach  *  has  also  come  to  the  conclusion  that 
"  the  mechanism  of  the  stomach  performs  its  functions  properly,  or 
is  very  slightly  disturbed,  in  spite  of  the  complete  cessation  of  this 
secretion."     Moreover,  in  the  course  of  the   experiments  on  the 

*  J.  Grundzach.  Ueber  nicht  carcinomatose  Ftllle  von  ganzlich  aufgehobener 
Absonderung  der  Magensaure  resp.  des  Magensaftes.  Berl.  klin.  Wochenschr., 
1887,  S.  543. 


480  DISEASES  OF  THE  STOMACH. 

effects  of  Carlsbad  water  mentioned  on  page  358,  I  liad  the  oppor- 
tunity of  examining  for  two  months  a  young,  robust  female  nurse, 
twenty-eight  years  old,  with  good  digestion ;  I  always  obtained  an 
unusually  low  degi-ee  of  acidity,  so  that  I  should  surely  have  re- 
ferred to  an  anomaly  of  secretion  any  complaints  which  she  might 
have  made  regarding  her  stomach.* 

Finally,  one  should  bear  in  mind  the  great  differences  observed  in 
these  investigations  in  the  daily  values  of  the  acidity  of  one  and  the 
same  person ;  these  can  vary  as  much  as  27  c,  c.  of  a  deci-normal 
solution  of  caustic  soda  for  100  c.  c.  of  gastric  juice.  This  is  due 
to  the  incompleteness  and  coarseness  of  our  present  methods,  which 
surely  give  no  information  of  a  number  of  delicate  changes  in  the 
chemistry  of  digestion. 

Undoubtedly,  the  normal  process  of  digestion  is  accompanied  by 
so  copious  a  secretion  of  hydrochloric  acid  that  not  alone  are  various 
combinations  formed  with  the  different  foods  present,  but  there  is 
also  a  certain  excess  of  free  acid  which  seems  to  be  indispensable 
for  the  completion  of  normal  gastric  digestion.  But  we  must  not 
forget,  as  I  showed  some  time  ago  in  the  digestion  of  albumen,f 
that  peptonization,  even  though  it  is  slight,  may  take  place  without 
any  free  acid ;  that  normally,  as  in  menstruation,  no  free  acid,  or 
only  a  very  small  quantity,  is  secreted ;  and  that  the  human  organ- 
ism manifestly  possesses  in  no  insignificant  degree  the  capacity  of 
compensating  for  an  absence  of  hydrochloric  acid,  pepsin,  and  ren- 
net by  driving  the  chyme  out  of  the  stomach  much  sooner,  and  rele- 
gating it  for  digestion  to  the  intestine. 

After  all  this  I  think  you  will  agree  with  me  if,  in  general,  I 
attribute  no  230sitive  diagnostic  value  to  the  simple  fact  that  the 
acidity  is  increased  or  diminished  or  apparently  normal,  provided 
this  is  referred  to  no  other  acids  than  free  hydrochloric  acid ;  and 
if  I  consider  such  results  only  as  a  supplementary,  although  very 

*  [It  would  be  well  if  these  important  facts  were  carefully  weighed  before  mak- 
ing the  diagnosis  of  atrophy  of  the  stomach  from  the  simple  absence  of  hydro- 
chloric acid,  pepsin,  and  I'ennet.  That  they  are  disregarded  is  shown  by  the  sur- 
prising number  of  such  cases  recently  reported  in  the  various  medical  journals 
without  corresponding  constitutional  symptoms. — Tr.] 

f  C.  A.  Ewald.  Ueber  den  "  Coefficient  de  partage  "  und  liber  das  Yorkommen 
von  Milchsiiure  und  Leucin  im  Magen.     Virchow's  Archiv,  Bd.  90,  S.  349. 


THE   PRACTICAL  VALUE   OF   CHEMICAL   TESTS.  481 

important,  feature  in  com^Dleting  and  establishing  the  entire  clinical 
picture.  On  the  other  hand,  I  do  not  wish  to  be  misunderstood, 
and  I  therefore  say  emphaticallv  that  this  statement  is  in  no  way 
intended  to  detract  from  the  value  of  our  examinations ;  on  the 
contrary,  they  are  indispensable  to  us,  and  in  all  cases  where  cir- 
cumstances will  not  permit  them  we  feel  in  doubt  and  "  somewhat 
at  sea." 

At  every  step  in  the  preceding  discussions  you  will  have  observed 
the  proof  of  the  extent  to  which  our  knowledge  has  been  extended 
and  amplified  by  the  new  methods  of  investigation ;  but,  on  the 
other  hand,  in  view  of  many  recent  events,  I  believe  it  is  my  duty 
to  warn  against  a  one-sided  overestimation  of  their  value.  Only  the 
most  careful  and  thorouo;h  consideration  and  weio-hino;  of  all  the 
symptoms  which  can  be  obtained  yydh  all  the  diagnostic  resources 
will  enable  us  to  recognize  the  existing  disease.  Xot  even  the 
most  careful  chemical  examination  of  the  functions  of  the  stomach 
will  put  within  our  grasp  the  divining-rod  which  will  magically  call 
forth  the  fountain  of  knowledge  from  the  adamantine  rocks  of 
obscure  symptoms  !     Even  to-day  the  old  saying  is  true  that — 

"  Ubi  ratio  sine  experimentis  mendax, 
Ita  experientia  sine  ratione  fallax." 


INDEX. 


Abercrombie,  84,  242. 

Abscess  of  stomach,  303. 

Absorption  in  stomach,  52,  370 ;  test  of, 

53. 
Acid,  acetic,  tests  for,. 35. 

butyric,  tests  for,  35. 

hydrochloric.  See  Hydrochloric  Acid. 

lactic,  in  stomach-contents,  33 ;  fer- 
mentation-, 33  ;  meat-,  33  ;  tests  for, 
33. 

salicyluric,  test  of,  in  urine,  55. 
Acid  salts,  tests  for,  23. 
Acidity  of  gastric  juice,  variations  of, 
480. 

of  stomach-contents,  20 ;  stages  of,  20 ; 
testing  of,  22,  37,  229. 
Acids,  fatty,   in  stomach-contents,  35 ; 
tests  for,  35. 

free,  tests  for,  23. 

organic,  tests  for,  32. 

See  also  Contents  of  Stomach. 
Acoria,  427. 

Adenopathies  in  gastric  cancer,  176. 
Adler,  471. 
Agoraphobia  in  chronic  gastritis,  331. 

in  gastric  neuroses,  389. 
Air,  distention  of  stomach  with,  59. 
Akinesis  of  stomach,  130. 
Albertoni,  216. 
Alberts,  J.  E.,  163,  166. 
Albumen,  digestion  of,  41,  43. 

disks,  47. 

putrefaction  of,  in  stomach,  141. 

reaction  on  aniline  dyes,  26. 

reactions  of,  42. 
Albutt,  12,  117,  145. 
Alcohol  in  contents  of  stomach,  35. 
Alderson,  5. 

Alimentation,  rectal,  105,  268. 
Alt,  432,  433. 
31 


Anacidity  of  gastric  juice,  187,  189,  337, 
479. 

nervous,  427. 

See  Hydrochloric  Acid,  Absence  of. 
Anadenia  of  stomach,  318,  334;  absence 
of  HCl  in,  337;  diagnosis,  339; 
pathology,  318 :  relation  to  perni- 
cious ana?mia,  335,  463  ;  treatment, 
341. 
Anaemia,  condition  of  stomach  in,  469. 

pernicious,  condition   of   stomach   in, 
335,  463. 
Anjesthesia  of  skin  in  gastric  ulcer,  245. 

of  stomach,  427. 
Andral,    136,   166,    176,    253,    304,    448, 

464. 
Aniline  dyes  in  stomach  analyses,  23. 
Anorexia,  397. 

in  cancer  of  stomach,  185. 

in  catarrh,  295. 

in  dilatation,  136. 

in  phlegmon,  305. 

in  tumors  of  kidney,  472. 

in  tuberculosis,  399,  464. 

in  ulcer  of  stomach,  246. 

nervous,  397. 
Antiperistaltic  unrest  of  stomach,  426. 
Appetite,  384. 

in  gastric  cancer,  206. 

lack  of.    See  Anorexia. 

perverse,  396. 

ravenous,  394. 
Ardor  ventriculi,  326. 
Aretaeus,  391. 
Arnold,  430. 
Arnott,  5. 
Asiatic  pills,  455. 
Asp,  331. 

Aspirator,  stomach,  12. 
Asthenia  of  stomach,  130. 


484 


DISEASES  OF   THE   STOMACH, 


Asthma,  dyspeptic,  320,  420. 
Atony  of  stomach,  144,  333,  435. 

in  chronic  gastritis,  328,  333. 

in  dilatation,  130. 
Atrophy  of  stomach.     See  Anadenia. 

of  muscularis  of  stomach,  139,  333. 
Audhui,  118. 

Auerbach's  plexus,  degeneration  of,  367. 
Aura  vertiginosa,  331. 

Bacillus  gastricus,  307. 
Bacteria  in  acute  gastritis,  288. 

in  gastric  cancer,  165. 

in  gastric  phlegmon,  304. 

in  gastric  ulcer,  233. 
Bamberger,  113,  133,  188. 
Baradui.  69. 
Barnes,  81. 
Barras,  362,  391,  424. 
du  Barry,  138,  139. 
Bartels,  129,  130,  336. 
A'on  Basch,  331. 
Baum,  157. 
Beau,  168,  363. 
Beaumont,  333,  387,  394,  348. 
Behrens,  60. 
Belching,  nervous,  418. 
Belladonna  in  cancer  of  stomach,  212. 
Benecke,  461. 
Bennet,  374. 
Benzopurpurin,  24. 
Bernabel,  133. 
Bernstein,  331,  467. 
Berthold,  333. 
Best,  199. 
Biernacki,  471. 
Bile  in  stomach-contents,  57. 

taste  of,  395. 
Binswanger,  457. 
Bircher,  158. 

Bird,  Golding,  187,  188,  190. 
Bismuth,  370. 
Bitters,  344. 
Biuret  reaction,  43. 
Blatin,  5. 
Blondeau,  331. 

Blood,  condition  of,  in  cancer  of  stom- 
ach, 186. 
condition    of,    in    ulcer    of    stomach. 

335. 
in  stools,  346,  347,  250,  277. 
vomiting  of.     See  H^matemesis. 
Blume,  278. 


Boas,  11,  12,  15,  21,  26,  31,  38,  44,  49,  50, 

52,  194,  230,  335,  339,  344,  354,  358, 

433,  449. 
Bocci,  68. 
Boerhave,  166. 
Bollinger,  199, 
Bouchard,  118. 
Bouilleaud,  253. 
Bourdon,  464. 
Bourneville,  429,  430. 
Braam-Houckgeest,  133. 
Brachet,  366. 
Bradypepsie,  313. 
Braun,  344. 
Brentano,  130. 
Bvieger,  466. 
Brinton,  73, 86, 162, 167, 171, 175, 177, 178, 

183,  185,  194,  233,  304,  306,  316,  474, 
Briquet,  390,  436,  441. 
Bristowe,  419. 
Bromide-water,  463. 
Broussais,  313,  406. 
Brown,  51,  406. 
Brown-Sequard,  301. 
Briiek,  331. 
Brunner,  157. 
Brunton,  Lauder,  284,  295. 
Brush,  stomach,  4. 
Buch,  405. 
Budd,  241,  351,  865,  377,  341,  353,  362, 

414,  448. 
Bukler,  305. 
Bulimia,  394;  etiology,  396  ;  forms,  397; 

occurrence,  395  ;  peristalsis  in,  397 ; 

treatment,  395,  451. 
Bull,  E.,  329. 
Bull,  W.  T.,  157. 

Burkart,  68,  407,  445,  457,  459,  460. 
Bush,  F.,  5. 
Bussel,  208. 
Buzelygan,  469. 

Cachexia,  in  gastric  cancer,  180,  203. 

in  hysteria,  202. 
Cahn,  21,  34,  45,  46,  113,  136,  134,  144, 
145,  188,  190,  193,  194,  229,  230,  303. 
Calculi,  gastric,  199,  393. 
Callow,  307. 
Camerer,  231. 
Camus-Corrignon,  333. 
Canstatt,  5,  173. 

Cancer  of  stomach.     See  Carcinoma. 
Canula,  permanent,  of  oesophagus,  97. 


INDEX. 


485 


Caragiosiadis,  08. 

Carbonic-acid  gas,  distention  of  stomach 

with,  59. 
Carcinoma  of  stomach,  163. 

bacteria  in,  165. 

course,  176. 

diagnosis,  186;  absence  of  hydi'ochlo- 
rie  acid,  187 ;  cachexia  in,  202  ;  can- 
cerous tumor,  197 ;  from  atrophy, 
840 ;  pieces  of  tissues  obtained  by 
washing  out  stomach,  195. 

differential  diagnosis,  204;  between 
gastric  ulcer  and  cancer,  206,  255. 

etiology,  165. 

lymphadenitis,  176. 

occurrence,  163 ;  age,  162 ;  heredity, 
163  ;  primary  or  secondary,  173  ;  re- 
lations to  gasti'ic  ulcer,  167  ;  sex,  163. 

pathological  anatomy,168;varieties,169. 

perforation,  177. 

prognosis,  182. 

propagation,  175. 

site,  171 ;  sequelas  of,  173. 

symptoms,  177  ;  anorexia,  178  ;  bow- 
els, 185  ;  cachexia,  180,  203 ;  pain, 
185 ;  presence  of  tumor,  197  ;  A^omit- 
ing,  178, 185 ;  vomiting  of  blood,  185. 

thrombosis,  176. 

treatment,  208  ;  analgesics,  212  ;  con- 
durango,  208  ;  diet,  213  ;  mineral  wa- 
ters, 215;  of  constipation,  213;  of 
ha?matemesis,  211 ;  of  vomiting,  311. 

ulceration,  176. 
Cardia,  cancer  of,  85. 

closure  of,  375 ;  in  rumination,  432. 

contraction  of,  spastic,  80. 

function  of,  375. 

neoplasms  of,  82. 

paresis  of,  438. 

relaxation  of,  419,  428,  432. 

spasm  of,  80. 

stenosis  of,  71. 

stricture  of,  71  ;  dilatation  of,  89  ; 
feeding  in,  104 ;  gastrostomy  in, 
100 ;  organic,  82 ;  pain  in,  75  ;  pas- 
sage of  bougies  in,  95 ;  symptoms, 
71 ;  treatment,  95. 
Cardialgia,  327,  400. 

in  gastric  cancer,  178. 

in  stricture  of  cardia,  75. 
Darlsbad  water,    action  of,  in    chronic 
gastritis,   358 ;  in   gastric  neuroses, 
463  ;  in  ulcer,  267. 


Carron,  81. 

Carswell,  171,  176,  236,  277. 

Cartellieri,  420. 

Catarrh  of  stomach.     See  Gastritis  Ca- 

TARRHALIS. 

Catarrh  us  atrophicus,  322. 

Celsus,  351. 

Chambers,  242,  363. 

Chantemasse,  233, 

Charcot,  403. 

Chausnes,  Due  de,  stomach  of,  137. 

Cherchewsky,  440,  445. 

Chiaje,  Delli,  99. 

Chiari,  334,  333. 

Chittenden,  50,  348. 

Chlorosis,  condition  of  stomach  in,  469. 

Chomel,  313. 

Chovstek,  354,  306. 

Cirrhosis  ventriculi,  316. 

Clapotement,  118. 

Cloizier,  131. 

Cohn,  426. 

Cohnheim,  165,  173,  227,  340,  281,  283. 

Coin,  81. 

Cold-water  treatment,  69. 

CoUeville,  473. 

Colloid  cancer  of  stomach,  170. 

Colic,  biliary,  363. 

stomach,  435. 
Coma  dyspepticum,  147. 

dyspnoeic,  183. 
Coinby,  136,  334. 
Comparetti,  363. 
Concretiones  benzoartic^es,  393. 
Condurango  in  gastric  cancer,  308. 
Congo-red,  34. 
Contents  of  stomach,  7,  11. 

acetic  acid  in,  35,  143. 

acidity  of.  30,  33,  37,  339,  480, 

alcohol  in,  35. 

bacteria  in,  307. 

bile  in,  57. 

butyric  acid  in,  35. 

fatty  acids  in,  33. 

fungi  in,  307. 

in  acute  gastritis,  388. 

in  gastric  crises,  403. 

in  gastric  cancer,  187. 

in  gastric  catarrh,  338. 

in  gastric  ulcer,  258. 

lactic  acid  in,  33. 

larv£e  in,  308. 

marsh-gas  in,  142. 


486 


DISEASES   OF   THE  STOMACH. 


Contents  of  stomach,  methods  of  obtain- 
ing, 12. 

micro-organisms  in,  307. 

defiant  gas  in,  142. 

organic  acids  in,  33,  35,  476. 

pepsin  in,  41,  194,  342. 

reaction  of,  20. 

rennet  in,  49,  194. 

taste  of,  295. 
Contraction  of  stomach,  173. 
Cooper,  232. 
Copland,  245,  313,  414. 
Cordes,  331,  332,  359. 
Cornil,  253. 
Cornillon,  260. 
Cough,  stomach,  329. 
Cramps  of  stomach,  390,  425 ;  in  gastric 

dilatation,  146. 
Cravate  de  Suisse,  374. 
Crises,  gastric,  403,  443,  472. 
Crisp,  227. 
Cruveilhier,  123,  133,  220,  239,  240,  268, 

304,  323. 
Cullen,  326. 
Cure,  rest,  266,  458. 

Schroth's  dry,  151. 
Curling,  232. 
Cynorexia,  394. 

Da  Costa,  269. 

Daettwyler,  222. 

Daguet,  260. 

Damaschino,  313. 

Danger  of  stomach-tube,  84,  260,  361. 

Darwin,  430. 

Daumann,  449. 

Debove,  277. 

Decker,  56,  157. 

Defecation  by  mouth,  426. 

Defaillance,  894. 

Degeneration,  colloid,  of  stomach,  205. 

Degeneration   of    nervous    plexuses    of 

intestines,  439. 
Deglutition-murmurs,  61. 

in  dilatation  of  stomach,  119. 

in  rumination,  432. 

stricture  of  cardia,  82. 
Dehio,  61,  114,  420. 
Deininger,  306. 
Dejerine,  402. 
Delamare,  402. 
Demange,  402. 
Depressive  neuroses  of  stomach,  427. 


Desnos,  426. 
Dettweiler,  468. 
Dextrin,  50. 

Diabetes,  condition  of  stomach  in,  478. 
Diarrhoea  due  to  terror,  369. 
Diemerbock,  144. 
Diet  in  gastric  cancer,  313. 
in  gastric  catarrh,  346. 
in  gastric  ulcer,  268. 
Dietrich,  259. 

Digestion  of  albumen,  41,  43 ;  test  of,  47. 
of  starch  and  sugar,  49. 
phases  of,  21. 

reflex  disturbances  of,  447. 
-test  in  gastric  neuroses,  438,  445. 
Dilatation  of  oesophagus,  89. 
Dilatation  of  stomach,  110. 
atonic,  130. 
course  of,  149. 

diagnosis  of,  112,  148;  auscultation, 
118;  inspection,  112;  measuring  ca- 
pacity of  stomach  in,  120 ;  murmurs 
of  deglutition  in,  119 ;  palpation, 
116 ;  percussion,  113 ;  Rosenbach's 
method  in,  119;  suceussion,  118. 
etiology,  120  ;  atony  of  stomach,  130  ; 
exclusion  of  limited  areas  of  mus- 
cular fibers  of  stomach,  133 ;  feeble- 
ness of  motor  nerves,  130,  132 ; 
polyphagia,  131 ;  stenoses  of  pylorus, 
123 ;  wandering  kidney,  129. 
occurrence,  130;  with  biliary  calculi, 

129. 
pathology,  133. 
physical  signs,  112. 
prognosis,  149. 

symptoms,  136 ;  chemical  functions  of 
stomach,  140 ;  coma,  147 ;  constipa- 
tion, 145  ;  delayed  absorption,  143  ; 
enlargement  of  stomach,  110 ;  fer- 
mentations, 128,  131,  141 ;  inflam- 
mable gases,  142;  peristalsis,  145; 
sarcina3  and  bacteria,  138;  stagna- 
tion of  stomach-contents,  141 ;  teta- 
ny, 146  ;  urine,  state  of,  147  ;  vomit, 
137 ;  vomiting,  137. 
treatment,  151 ;  dry  diet,  151 ;  resec- 
tion of  pylorus,  157;  use  of  cathar- 
tics, 154  ;  faradization,  156  ;  hydro- 
chloric acid,  153 ;  massage,  156 ; 
strychnine,  153 ;  washing  out  stom- 
ach, 154. 
Diphtheritic  gastritis,  302. 


INDEX. 


487 


Dirksen,  61,  G3. 

Distention  of  stomach,  with  air,  59. 

with  carbonic-acid  gas,  59. 

witli  water,  01. 
Dittrich,  106, 107,  175,  177,  181,  304 
Diverticula  of  cesophagus,  89. 
Douche,  Scotch,  157,  456. 

stomach,  63,  453. 
Dreschfeld,  188. 
Drozda,  254. 
Dubujadoux,  316. 
Ducasse,  431. 
Dujardin  Beaumetz,  118,  146,  153,  163, 

341,  352. 
Dunglison,  245. 
Duodenum,  ulcer  of,  232,  264. 
Duplar,  118,  153. 
Dupuytren,  232. 
Dusart,  70. 
Dyspepsia,  313. 

asthenique,  130. 

atonic,  313. 

cardiaca,  330. 

flatulent,  440. 

in  gastric  cancer,  178. 

in  gastric  dilatation,  136. 

in  stricture  of  eardia,  72. 

irritable,  313. 

nervous,  387,  437. 

reflex,  439,  449. 

uterina,  449. 

Also  see    Chroxic    Catarrhal    Gas- 
tritis. 
Dyspoenic  coma  in  gastric  cancer,  182. 
Dyspeptic  asthma,  330. 

Eating,  slow,  346. 

repugnance  toward,  397. 
Ebstein,  60,  222,  291,  309,  323,  434,  435. 
Edinger,  16,  225,  393,  301,  466. 
Egeberg.  100. 

Einhorn,  19,  63,  66,  157,  336. 
Eisenlohr,  186. 

Electrization  of  stomach,  65,  156,  344. 
Electrode,  stomach,  66. 
Elixir  peptogene,  341. 
Ellenberger,  50. 
Ely,  173. 

Emerald  green,  35. 
Emminghaus,  14. 
Emptiness  of  stomach,  394. 
Engel,  254. 
Enemata  in  chronic  gastritis,  355. 


Enemata,  nutritive,  105. 

Eppinger,  241,  243. 

Erichsen,  210,  232. 

Ergot,  in  haematemesis,  216,  279. 

Erlenmeyer,  454. 

Erosion,  haemorrhagie,  of  stomach,  236. 

Eructation,  foul-smelling,  142. 
hysterical,  419. 
nervous,  418. 

Escherich,  328. 

Etat  mammelone,  135. 

Ether,  extraction  with,  34. 

Examination  of  stomach,  58. 

Ewald,  C.  A.,  5,  13,  38,  30,  41,  46,  50,  53, 
54,  61,  68,  85,  91,  105,  133,  141,  143. 
157,  188,  300,  233,  326,  385,  392,  301, 
311,  315,  318,  336,  341,  344,  348,  354, 
364,  376,  449,  460,  466,  471,  480. 

Ewald,  R.,  363. 

Expression,  Ewald's  method  of,  12. 

Eyeselein,  831. 

Faber,  52,  251,  260. 
Fabricius  ab  Aquapendente,  429. 
Fagge,  Hilton,  145. 
Falkenheim,  138. 
Fames  canina,  394. 
Faradization  of  stomach,  65,  156. 
Fauvel,  353. 
Favus  of  stomach,  307. 
Fawizky,  38. 
Feeding  by  rectum,  105. 
Fenwick,  S.,  318.  336,  362,  399,  464. 
Fenwick,  W.  S.,  361,  463,  471. 
Ferber,  114. 
Fermaud,  309. 

Fermentation  (alkaline)  of  albuminoids 
in  stomach,  141,  328. 

in  stomach,  155,  288,  351. 

lactic  acid,  33. 
Finkler,  343. 
Finny,  248. 

Fistula  of  stomach,  making  of,  91,  100. 
Fistul;e  after  perforation  of  gastric  ulcer, 

252. 
Flatow,  167. 
Fleischer,  449. 
Flint,  335. 
Food,  taking  of,  385. 

refusal  of,  397. 
Forster,  236. 
Forster,  266. 
Fothergill,  362. 


488 


DISEASES   OP   THE   STOMACH. 


Fouquet,  426. 

Fox,  Wilson,  163,  228,  266. 

Frankel,  E.,  308. 

Frerichs,  von,  5,  59,  83,  84,  138,  183,  204, 

254. 
Freund,  318. 
Friedreich,  181,  208. 
Fries,  276. 
Fuchsiu,  25. 
Full  stomach,  390. 
Fungus  hagmatodes  of  stomach,  170. 
Fiirstner,  68. 
Fungi  in  stomach-contents,  140. 

Gallard.  279. 
Galliard,  242,  254 
Gallois,  480. 

Ganglion-cells  of  stomach,  367. 
Gans,  473. 

Gastralgia,  243,  327,  400. 
genuine,  401. 
hysterical,  410, 

diagnosis  from  ulcer  and  cancer,  254. 
in  diseases  of  central  nervous  system, 

408. 
in  gastric  cancer,  185,  206,  212. 
in  gastric  ulcer,  243,  246. 
in  gastric  neurasthenia,  406. 
in  psychoses,  413. 
nervous,  diagnosis  of,  255. 
reflex,  447. 

treatment  of,  212,  272,  451,  452. 
upon  a  constitutional  basis,  405. 
Gastrectasis.     See  Dilatation  of  Stom- 
ach. 
Gastric  crises,  403,  443,  472. 
Gastric  fever,  296. 
Gastric  juice.    See  Juice,  Gastric. 
Gastric  neurasthenia,  437. 
Gastritis,   acute,    287  ;    glandular,   287 ; 
idiopathic,   287 ;    sympathetic,   301 ; 
acidity  in  sympathetic,  301. 
simple  acute,  287  ;  diagnosis,  296 ;  eti- 
ology,  287;    fermentation    in,   290; 
hydrochloric  acid  in,  290 ;  lactic  acid 
in,  290 ;  occurrence,  287 ;  pathology, 
291 ;  stomach-contents  in,  290 ;  symp- 
toms, 294 ;  treatment,  299  ;  varieties, 
294. 
chronic   glandular,  313;    agoraphobia 
in,  331 :  anadenia  in,  see  Anadenia  ; 
antifermentatives  in,  351 :  anodynes 
in,  352;  atony  of  stomach  in,  328, 


332  ;  bitters  in,  344;  constipation  in, 
328 ;    course,   340 ;    diagnosis,   337 
diet   in,  346 ;  dyspeptic   asthma  in 
331 ;  enemata  in,  355  ;  etiology,  324 
hydriatic  treatment  of,  346 ;  hydro 
chloric  acid  in,  341 ;  lavage  in,  343 
mineral    waters    in,    356  ;    minute 
anatomy    of,   316 ;    orexin   in,   346 
papoid  in,  343 ;  panereatin  in,  343 
pathology  of,  315 ;  pepsin   in,  342 
prognosis  of,  340 ;  purgatives  in,  353 
stomach-cough  in,  329;   symptoms, 
325 ;  synonyms,  313  ;  treatment,  341 
urine   in,  329;    varieties,  325,  338 
vertigo  in,  331 ;  vomiting  in,  327. 
diphtheritic,  289,  302. 
emphysematous,  308. 
membranous,  289. 
mucous,  325,  338. 
mycotic,  307. 
parasitic,  307. 

purulenta  phlegmonosa,  303 ;  diagno- 
sis, 306;  etiology,  304;  occurrence, 
304 ;  pathology,  304  ;  symptoms, 
305 ;  treatment,  307. 
toxic,  309  ;  diagnosis,  311 ;  symptoms, 
310;  treatment,  311. 

Gastroadenitis,  287. 

Gastrodiaphane,  63. 

Gastrodynia,  400. 

Gastroenterite,  313. 

Gastroliths,  199,  392. 

Gastroscope,  62. 

Gastroscopy,  62. 

Gastrostomy,  100. 
feeding  after,  103. 
technique  of,  102. 

Gastroxynsis,  418. 

Gavarett,  176. 

Gempt,  Te,  269. 

Gerhardt,   146,  177,  229,  233,  247,  264, 
271,  309. 

Germont,  186. 

Gersung,  98. 

Gigglberger,  348. 

Gilles-Sabourin,  241. 

Girandeau,  118. 

Gliiser,  306. 

Glax,  113,  304,  426,  474. 

Gluczinsky,  188,  190,  469. 

Glycerin  suppositories,  356. 

Gmelin,  15. 

Goldstein,  253. 


INDEX. 


489 


Goltz,  370,  376. 

Gorabault,  316. 

(loodhart,  456. 

Goodsir,  138. 

Cxout,  condition  of  stomach  in,  473. 

Graves,  327. 

Griess,  233. 

Griffini,  231. 

Griinfeldt,  234. 

Griitzner,  292,  344. 

Grundzach,  479. 

Grusdew,  467. 

Glinsburg,  231. 

Glinzbui-g,  29,  31,  32,  48. 

Guipon,  396. 

Gull,  402. 

Gumlich,  46. 

Gussmann,  296. 

Haafewinkel,  343. 
Haas,  32. 

Habershon,  239,  304. 
Hasmatemesis,  276. 

causes  of,  277. 

diagnosis  from  haemoptysis,  276. 

in  cardiac  diseases,  277. 

in  cholera,  278. 

in  diseased  gastric  blood-vessels,  279. 

in  epilepsy,  277. 

in  fever,  intermittent,  278. 

in  fevers,  exanthematous,  278. 

from  oesopliageal  varix,  277. 

in  gastric  ulcer,  245. 

in  gastritis  glandularis  chronica,  278. 

in  hysteria,  278. 

in  liver,  acute  yellow  atrophy  of,  277. 

in  liver,  cirrhosis  of,  277. 

in  progressive  anasmia,  279. 

in  purpura  hemorrhagica,  278. 

in  scurvy,  278. 

treatment  of,  in  cancer,  211:  in  gen- 
eral, 279  ;  in  ulcer,  273. 
Hgemoptysis,  276. 
Hafner,  278. 

Hair-tumors  in  stomach,  199,  393. 
Hall,  253. 
Haller,  379. 

Haller's  acid  elixir,  280. 
Hampeln,  181. 
Hanot,  86,  316. 
Hart,  Wheatley,  90. 
Hauser,  167,  235. 
Hayem,  40,  469. 


Heart,  condition  of  stomach  in  diseases 
of,  4G4,  470. 

Heart-burn,  314,  326,  420. 

lleberden,  341. 

Heidenhain,  236,  295. 

Heredity  of  cancer,  163. 

Ileinecke,  157. 

Heisshunger,  394. 

Heitler,  167. 

Henle,  236. 

Henoch,  176,  186,  234,  277,  297,  330,  420. 

Henry,  464. 

Heron,  51. 

Herpes  labialis  in  chronic  catarrhal  gas- 
tritis, 295. 

Herzen,  341. 

Hildebrand,  309,  466,  467. 

Hiller,  254. 

Plilton,  274. 

Hippoci'ates,  391. 

Hirsch,  21,  230. 

Hoesslin,  von,  24,  36. 

Hoffmann,  F.  A.,  287,  288. 

Hofmeister,  50. 

Holmes,  232. 

Hoppe-Seyler,  301. 

Honigmann,  230,  414,  418. 

Hornbaum,  405. 

Huber,  56,  107. 

Hubert,  157. 

Hubner,  414. 

Hufler,  470,  471. 

Hiippe,  141. 

Hufeland,  208. 

Hughes,  274. 

Hunger,  379. 
causes  of,  379. 
center  of,  363,  380. 

feeling  of,  380 ;  deviations  from,  394 ; 
inhibition  of,  382;  localization,  381; 
voracious,  394. 

Hunter,  4. 

Hutchinson,  464,  467. 

Hydrochloric  acid,  absence  of,  in  Addi- 
son's disease,  190 ;  in  amyloid  de- 
generation of  gastric  mucosa,  189 : 
in  anadenia,  337;  in  gastric  cancer, 
187;  in  gastric  neuroses,  189;  in 
menstruation,  449 :  in  mucous  ca- 
tarrh of  stomach,  189 ;  permanent, 
in  healthy  persons,  479 ;  in  pulmo- 
nary phthisis,  190,  467;  in  valvular 
diseases,  470. 


490 


DISEASES   OP   THE   STOMACH. 


Hydrochloric  acid,  antiseptic  action  of, 
287. 

free  and  combined,  36,  37,  38. 

permanent  lessening  in   gastric  neu- 
rosis, 477. 

tests  for,  25,  37,  38. 

use  of,  153,  341. 
Hydrops  in  gastric  cancer,  181. 
Hydrotherapy,  66,  424,  454,  456. 
Hyperacidity,  414. 

in  gastric  ulcer,  229,  258. 

in  nervous  disorders,  415. 

test  of,  22. 
Hypersesthesia  of  stomach,  890. 

after  chloroform  narcosis,  392. 
Hyperorexia,  394. 
Hypersecretion  of  gastric  juice,  414,  415. 

diagnosis,  418. 

in  cerebral  disorders,  448. 

periodical,  415. 
Hypersecretio  acida,  414,  415. 
Hypochondria.  396. 
Hysteria,  389,  400,  405,  410. 

Idiosyncrasy  of  stomach,  393. 
Immermann,  209,  466,  467. 
Indigestion,  303,  313. 
Innervation  of  stomach.  363. 
Insufficiency  of  stomach,  137.     See  Py- 
lorus and  Cardia. 
Invert  sugar,  49. 
Iodoform  reaction,  Lieben's,  35. 
Intestines,  disturbed  digestion  of,  440. 

electrization  of,  67. 

hasmorrhage  in,  246,  247,  250,  277. 

tympanites  of,  435. 

vicarious  action  of,  53,  195.  335.  480. 
Iron,  albuminate  of,  269,  456. 
Irritative  gastric  neuroses,  390. 

Jaksch,  von,  24,  39,  233. 

Jaccoud,  426. 

Jaworski,  11,  18,  54,  188,  267,  339,  342 

344,  346,  358,  414-416,  418,  467. 
Johannessen,  429. 
Johnson,  391. 
Jolly,  415. 
Jones,  H..  277,  464. 
Juice,  gastric,  acidity  of,  22. 

changes  in,  significance  of,  476. 

flow  of,  414;  continual,  416;  in  cere- 
bral affection,  448  ;  periodical,  416. 

hyperacidity  of,  414. 


Juice,  gastric,  hypersecretion  of,  415. 

in  gastric  catarrh,  341. 

in  gastric  cancer,  187. 

in  gastric  dilatation,  140. 

in  gastric  neuroses,  446. 

in  gastric  ulcer,  229. 

in  rumination,  433. 

parasecretion,  415. 

secretion  of,  16,  315. 
Julien,  254. 
Jiirgens,  439. 
Jiirgensen,  418,  433. 

Kaczarowski,  346. 

Kahlden,  316. 

Kahler,  26,  29,  402. 

Kalmus,  302. 

Katzenellenbogen,  171,  176. 

Kidney,  condition  of  stomach  in  dis- 
eases of,  464,  471. 

Kietz,  188. 

Kinnicutt,  16,  157. 

Kisch,  449,  474. 

Klebs,  253,  292,  307. 

Kleef,  274. 

Kleist,  354. 

Klemperer,  G.,  25,  49,  56,  57,  122,  301, 
466,  467. 

Robert,  376. 

Koch,  222. 

Kocher,  101. 

Kohler,  190. 

Kollmar,  257. 

Konig,  18. 

Kooyker,  392. 

Korner,  431. 

Kossel,  450. 

Kraus,  32. 

Ki-etschy,  449. 

Krishaber,  97. 

Kronecker,  61,  91. 

Krukenberg,  28,  32,  188,  402. 

Kuhn,  32. 

Kundmann,  4. 

Kundrat,  307,  334. 

Kunze,  216. 

Kupffer,  292,  317. 

Kussmaul,  5,  68,  105,  111,  118,  125,  134, 
145,  146,  154,  155,  158,  187,  425,  434, 
437,  452. 

Laache,  186. 
Lab-enzyme,  49. 


INDEX. 


491 


Lab-ferment,  48. 

Lab-zymogen,  49. 

Labastide,  341. 

Laborde,  70. 

Laboulbene,  311. 

Lactic  acid.     See  Acid,  Lactic. 

Lambl,  445. 

Lanceraux,  253. 

Landau,  130. 

Landerer,  125. 

Landoiizi,  402. 

Lang,  254. 

Lange,  175,  239. 

Laprevotte,  146. 

Large  stomach,  112. 

Lavage  of  stomach,  63,  154,  343. 

Lebert,  134,  162,  163,  167,  171,  175-177, 

181,  183,  185,  195,  215,  233,  294,  304, 

305,  314. 
Ledoux-Lebard,  167. 
Leichtenstern,  91,  119,  360. 
Lemaitre,  323. 

Leo,  16,  35,  38,  39,  48,  272,  397. 
Lepine,  25,  186. 
Lesser,  310. 
Lesshaft,  117. 
Letulle,  232,  2-79. 
Leube,  4,  5,  14,  19,  49,  68,  105.  116,  129, 

227,  258,  266,  271,  272,  307,  362,  442, 

445,  452,  474. 
Leucin,  reaction  of,  28. 
Leudet,  253. 
Lewin,  W.;  306. 
Lewy,  318. 

Leyden,  97,  404,  424„  443,  457,  468. 
Liebermeister,  468. 
Liebreicb,  271,  445. 
Lienteric  stools,  186,  250. 
Litmus-paper,  22. 
Litten,  129,  147,  241,  336. 
Liver,  condition  of  stomach  in  diseases 

of,  472. 
Loreta,  157. 
Loeb,  147. 
Losch,  291. 
Louis,  464. 
Low,  232. 
Loye,  68. 
Lublinski,  309. 
Lugol's  solution,  51. 
Lung,  hfemorrhage  from,  276. 
Luschka,  72. 
Luton,  171. 


Mackenzie,  96,  97,  101. 

Macleod,  305. 

MacNaught,  142,  327. 

Magendie,  370. 

Maier,  125. 

Malachite  green,  25. 

Malaria,  condition  of  stomach  in,  474. 

Malbranc,  129,  452. 

Malibran,  136. 

Maltose,  50. 

Malvoz,  216. 

Mannskopf,  153. 

Marcet,  224. 

Marcone,  344. 

Marfan,  254,  292,  464. 

Martin,  147,  156. 

Martin,  St.,  108. 

Massage  of  stomach,  69,  156,  344,  453. 

Mastcur.     See  Rest-cure. 

Mathieu,  132. 

Mayer,  331. 

Meat-juice,  152. 

Meat  peptone,  152. 

chocolate,  152. 

Kemmerich's,  152. 

Koch's,  153. 

solution,  Leube's,  114. 
Meckel,  117. 

Medullary  carcinoma  of  stomach,  169. 
Megastria,  112. 
Meissner's  plexus,  367,  439. 
Melaena,  277. 
Mel^enemesis,  179. 

Melanotic  carcinoma  of  stomach,  69. 
Meltzer,  61,  82,  91. 
Menassein,  292,  301. 
Mering,  von,  21,  51,  188,  193,  229,  230. 
Merycismus,  429. 
Meschede,  309. 
Methyl  violet,  27. 
Meyer,  C,  167. 
Meyer,  G.,  236,  320,  322,  454. 
Meyer,  R.,  134. 
Meyer,  W.,  211. 
Michaelis,  274. 
Middeldorf,  253. 
Mikulicz,  62.  157,  408. 
Milk  diet,  349. 

peptonized,  152,  214. 
Miller,  131. 
Milliot,  67. 
Mineral  springs,  treatment  at. 

in  gastric  cancer,  215. 


492 


DISEASES   OF   THE   STOMACH. 


Mineral  springs,  treatment  at. 

in  gastric  catarrh,  356. 

in  gastric  neuroses,  402. 

in  gastric  ulcer,  275. 
Mineral  waters  in  gastric  neuroses,  455. 
Minkowski,  128, 132, 139, 140, 147,153,155. 
Mintz,  37. 
MiqueL  227. 
Mislowitzer,  177. 
Mitan,  350. 

Mitchell,  Weir,  457,  459,  460. 
Mobius,  440. 
Models  of  stomach,  110. 
Mohr,  22,  29. 
Montegre,  431. 
Morner,  38. 
Mosetig-Moorhof,  211. 
Motility.     See  Movements  of  Stosiach. 
Movements  of  stomach,  53,  373. 

in  bulimia,  397. 

in  chronic  catarrhal  gastritis,  332. 

tests  of,  53. 
Mucous  gastritis,  325,  338. 
Mucous  glands  of  stomach,  294. 
Mucous  membrane  of  stomach,  atrophy 
of,  318,  334. 

degeneration  of,  granular,  319. 

fungi  of,  307. 

hajmorrhage  in,  230. 

polypi  of,  323. 

vacuoles  in  cells  of,  317. 
Miiller,  Fr.,  147,  198,  250. 
Mliller,  Joh.,  364. 
Murchison,  180,  253,  254. 
Ilurmur,  deglutition  (Schluckgerausch), 
61,  119,  432. 

gurgling,  118. 

press,  61,  432. 

splash,  118. 

squirt,  61,  432. 

succussion,  118. 
Muscularisof  stomach,atrophyof,134,322. 

feebleness  of,  130. 

hypertrophy  of,  134. 

paresis  of,  334. 
Musser,  242,  254. 
Myalgia  of  abdominal  muscles,  390. 

jSTatanson,  01. 
Naunyn,  132,  155. 
Nausea,  390. 
Nauwerck,  128. 
Nencki,  54. 


Neptune's  girdle,  424,  456. 

Nerves  of  stomach,  360. 

Nervous  system,  condition  of  stomach  in 

diseases  of,  464,  472. 
NeschaiefE,  109. 
Neuralgia,  visceral,  442. 
Neurasthenia,,  406. 

gastric,  437. 

gastro-intestinal,  441. 

vago-sympathetic,  441. 
Neuroses  of  stomach,  301,  387.  414. 

conditions  of  depression  in,  427. 

conditions  of  irritation,  390. 

classification  of,  387. 

etiology,  388, 

mixed  form,  437. 

occurrence,  388. 

reflex,  447. 

relations  to  other  neuroses,  389. 

treatment,  450. 
Nicaladoni,  89. 
Niemeyer,  331. 
Nissen,  274. 
Nolte,  233. 

Norden,  Von,  230,  403,  414,  415. 
Normal  soda  solution,  22. 
Nothnagel,  129,  321,  336,  445. 

Odier,  271. 
Odytmann,  356. 
CEsophageal  probang,  6. 

sound,  78. 

tube,  6. 
Oesophagus,  dilatation  of,  89. 

diverticula  of,  89. 

permanent  canula  of,  97. 

sounding  of,  77. 

strictui-e,  cicatricial,  83 ;  spasmodic,  80. 

ulcer   of,   corrosion,   82  ;    round,   83  ; 
syphilitic,  83  ;  tubercular,  83. 
Oettinger,  146. 
Oil-test  57. 
Oppenheim,  402. 
I'orange  Poirier,  23. 
Orexin,  346. 

Organic  acids.     See  Acids, 
Orszewsky,  210. 
Orth,  307,  308,  310. 

Oser,  0,  10,  59,  00,  121,  129,  151,  250,  267, 
344,  302,  370,  387,  391,  404,  412,  453. 
Osier,  330,  404. 
Ott,  185,  198,  200,  206. 
Overloading  of  stomach,  291. 


INDEX. 


493 


Piicanowski,  115. 
Pain,  epigastralgic,  441. 

epigastric,  390. 

in  cancer,  185,  201,  200. 

in   catarrh   of   stomach,   febrile,   205 ; 
chronic,  328. 

in  hyperaesthesia  of  stomach,  390. 

in  hypersecretion  of  gastric  juice,  417. 

in  hysterical  gastralgia,  410. 

in  nervous  dyspepsia,  444. 

in  neurasthenic  gasti'algia,  406. 

in  stricture  of  the  carclia,  75. 

in  ulcer  of  stomach,  263. 
Pal,  56. 
Palpation  of  stomach,  58. 

tip  of  stomach-sound,  116. 
Pauli,  136. 

Pavy,  225,  227,  395,  474. 
Peiper,  468. 

Pemberton,  267,  391,  414. 
Peuzoldt,  52,  61,  118,  120,  144,  154,  346, 

348. 
Pepper,  69,  156. 
Pepsin,  artificial,  41. 

and  hydrochloric  acid,  digestion  by,  47. 

glycerin  of,  41. 

in  chronic  catarrhal  gastritis,  342. 
Pepsinogen,  339. 
Peptone,  42. 

artificial,  104. 

chocolate,  104. 

enema,  105. 

pastilles,  Maggi's,  152. 

reactions  of,  42. 

suppositories,  105. 
Peptonuria  in  gastric  dilatation,  148. 
Perforation   in   gastric   cancer,   178 ;   in 

gastric  ulcer.  249. 
Perforation-peritonitis,  274. 
Peristalsis  of  stomach,  373. 
Pertik,  123. 
Peyer,  395. 
Pfeiffer,  358. 

Pfungen,  Yon.  39,  230,  272,  332,  416,  436. 
Phenolphthallein,  22. 
Phlegmon,  perigasti'ic,  302. 

gastric.     See  Gastritis  phlegmonosa. 
Phloroglucin-vanillin,  29. 
Phthisis  ventriculi.     See  Anadema. 
Pick,  469. 
Pidoux,  474. 
Pinel,  391. 
Piorry,  61. 


Pitt,  232. 

Playfair,  457. 

Pneumatosis,  420. 

Points,  painful,  Burkart's.  407,  441. 

Poirier,  I'orange,  23. 

Poensgen,  433. 

Poisoning,  309. 

■with  alcohol,  .309  ;  caustic  alkalies,  310 ; 
hydrochloric  acid,  310  ;  nitrobenzol, 
311;  oxalic  acid,  310;  phosphorus, 
310;  sulphuric  acid,  310. 
Poisson,  249. 
Polyphagia,  427. 
Polypi  of  stomach,  323. 
Portal,  137. 

Position,  vertical,  of  stomach,  117. 
Potassium  ferrocyanide  in  Mohr's  test, 

29. 
Potton,  395. 
Powell,  249. 
Power,  81. 
Pribram,  63,  331. 

Probefriihstiiek.     See  Test -breakfast. 
Probemahlzeit.     See  Test-meal. 
Probemittagbrod.     See  Test-dinner. 
Proenzyme,  49. 
Propeptone,  43. 

reactions  of,  42. 
Proteolysis,  46. 
Ptyalin]  50. 
Ptyalisra,  reflex,  449. 
Pump,  stomach,  6,  12. 
Puncta  dolorosa.     See  Points,  Painful. 
Purgative,  Oydtmann's,  356. 
Purgatives,  353. 
Purgecz,  120. 

Pylorus,  cancer  of.     See   Carcinoma  of 
Stomach. 

closure  of,  375. 

functions  of,  375. 

hypertrophy  of  museularis  at,  200,  205. 

incontinence  of,  434. 

relaxation  of,  428. 

spasm  of,  425. 

spastic  contraction  of,  127. 

stenosis  of,  cicatricial,  122  ;  congenital, 
123  ;  hypertrophic,  125  ;  mechanical, 
123. 

ulcer  at,  229. 
Pyrosis,  314,  326,  420. 

Quenu,  465. 

Quincke,  61,  80,  83,  148,  222,  336. 


494: 


DISEASES   OF   THE  STOMACH. 


Rampold,  185. 

Raudnitz,  49. 

Kay,  274. 

Reaction,  ethyldiacetic  acid  (in  urine), 
147.  (For  other  reactions  see  under 
individual  headings.) 

Reagent,  Boas's,  81. 
Glinzburg's,  29. 
Mohr's,  29. 
UflEelmann's,  33. 

Recklinghausen,  Von,  302. 

Reflex  dyspepsia,  439,  449. 

Reflexes  from  other  organs  on  the  stom- 
ach, 447. 

Regnard,  68. 

Regurgitation,  428. 
in  stricture  of  oesophagus  and  cardia, 
70,  73. 

Reichmann,  414,  417. 

Reischauer,  32. 

Relations,  mutual,  of  stomach,  liver,  and 
intestines,  281 ;  and  nervous  system, 
864  ;  other  organs,  463. 

Rennet.     See  Lab. 

Renvers,  97. 

Resorcin,  31. 

Rest-cure,  Leube-Ziemssen,  266 ;  in  ul- 
cer, 266. 
Weir  Mitchell,  457. 

Retzius,  210. 

Rheumatism,  condition  of  stomach  in, 
474. 

Richet,  108,  368. 

Richter,  189,  408,  443. 

Riegel,  19,  109,  141,  188,  194,  229,  231, 
258,  414,  417,  418. 

Rieger,  66. 

Riess,  209,  454. 

Ritter,  21,  230. 

Roberts,  347,  352. 

Rodzajewski,  488. 

Rompler,  158. 

Rokitansky,  85,  129,  223,  231,  232,  236, 
238,  304. 

Rosenbach,  111,  119.  136,  188,  197,  330, 
451,  452. 

Rosengart,  336. 

Rosenheim,  17,  21, 188, 193,  229,  259,  336. 

Rosenstein,  426,  473. 

Rosenthal,  105,  362,  397,  402,  404,  406, 
408,  410,  419,  452,  454. 

Rosenthal,  C,  49,  190,  466,  468. 

Rosin,  16. 


Ross,  313. 

Rossbach,  418. 

Rossier,  481,  433. 

Rowing  in  chronic  catarrhal  gastritis, 350. 

Rubin,  25. 

Ructus.     See  Eructation. 

Ruhle,  468. 

Rumination,  429. 

Rumsseus,  4. 

Runeberg,  59. 

Rupture  of  stomach,  310. 

Ruppstein,  142. 

Rutherford,  355. 

Saceharification,  49. 

by  saliva,  50. 
Sachs,  292. 
Sahli,  48. 
Salkowski,  38. 
Salol  test,  54. 
Saly,  414. 
Samuelson,  226. 
Sanctuary,  127. 
Sandberg,  358,  479. 
SarcinsB  ventriculi,  138,  245. 
Sassezky,  301. 
Satiation,  feeling  of,  384. 

lack  of,  894. 
Saundby,  278,  455. 
Sauvage,  433. 
Scheperlen,  336. 
Scherf,  253. 
Schetty,  301,  466. 
Scheuerlen,  166. 
Schiff,  222,  841,  366. 
Schill,  166. 
Schillbach,  67. 
Schliep,  14. 
Schlesinger,  104,  151. 
Schluckgeriiusch.    See  Murmur,  Deglu- 
tition. 
Size  of  stomach,  115. 
Situation  of  stomach,  117. 
Schmidt,  P.,  296. 
Schmidt-Miihlheim,  144,  372. 
Schraidtmann,  891,  429. 
Schneider,  186,  429,  430. 
Schnetter,  59. 
Schonborn,  199. 
Schrader,  880. 
Schreiber,  16,  120. 
Schroth's  dry  diet,  151. 
Schuchardt,  166. 


INDEX. 


495 


Schiitz,  60,  129,  420. 

Soirrhus  of  stomach,  109. 

Sclerosis,   hypertrophic,  of   gastric   sub- 

mucosa,  317. 
Secretion  of  stomach,  3G7. 
Sedgwick,  234. 
Scdillot,  100. 
See,   Germain,   112,  118,   127,   132,  148, 

260,  314,  346,  353. 
Seeraann,  28. 
Seglas,  429,  430. 
Sehrwald,  226. 
Senator,  286,  309,  397. 
Senn,  158. 
Sensibility  of  the  stomach,  377 ;  morbid, 

391.  " 
Sere,  De.  434. 

Shape  of  stomach,  changes  in.  111. 
Sialorrhoea,  449, 
Siebert,  353. 
Sievers,  54,  68,  157,  433. 
Siewecke,  205. 
Silbermann,  222. 
Silberstein,  56. 
Silver  nitrate,  271. 
Simple  gastritis,  325. 
Singer,  30. 
Siphon,  stomach,  6. 

Siphonage  in  washing  out  stomach,  63. 
Sjoqvist,  38. 
Skin,  anaesthesia  of,  in  gastric  ulcer,  245. 

hyperaesthesia  of,  in  gastric  ulcer,  345. 

condition  of  stomach  in  diseases  of, 
474. 
Skjelderup,  153. 
Skoda,  295. 
Smaragd  green,  25. 
Smirnow,  289,  302. 
Snow,  164. 

Soda  solution,  normal,  22. 
Sodium  chloride,  reaction  of,  26. 
Sohlern,  Von,  233. 
Sommerville,  5. 
Sonnenberg,  92,  97,  102. 
Sounding  of  stomach,  10. 
Sounds,  oesophageal,  78. 

stomach,  6. 
Spallanzani,  16. 

Springs,  mineral,   treatment  at,  in  gas- 
trie  cancer,  215  ;  catarrh,  356 ;  neu- 
roses, 455,  461 ;  ulcer,  275. 
Stabchen  plessimeter  percussion,  119. 
Starch,  digestion  of,  49. 


Starck,  233. 

Status  gastricus,  313. 

Stern,  471. 

Stewart,  306. 

Stienon,  193. 

Stiller,  362,  389. 

Stintzig,  292. 

Storck,  208. 

Stomach,  anadenia  of.     See  Axadenia. 

atony  of.     See  Atoxy, 

atrophy  of.     See  Atrophy. 

carcinoma  of.     See  Carcixoma. 

catarrh  of.     See  Gastritis  catarrha- 

LIS. 

contents  of.  See  Coxtents  of  Stom- 
ach. 

depressive  conditions  of,  427. 

dilatation  of.  See  Dilatation  of 
Stomach. 

ha3morrhage  in      See  H^matemesis. 

inflammation  of,  purulent.  See  Gas- 
tritis phlegmoxosa.  Inflammation 
of,  toxic.   See  Gastritis,  Toxic. 

innervation  of,  363. 

irritative  conditions  of,  390. 

large,  113. 

models  of,  110. 

motility  of.  Sec  Movemexts  of  Stom- 
ach. 

mucous  membrane.  See  Mltcous  Mem- 
braxe. 

neuroses  of.  See  Xeueoses  of  Stom- 
ach. 

phthisis  of.     See  Axadexia. 

ulcer  of.     See  Ulcer  of  Stomach. 

unrest  of,  antiperistaltic,  426 ;  peri- 
staltic, 145,  425. 

vaso-motor  nerves  of,  371. 

washing  of,  63,  154,  343 ;  in  poisoning, 
311. 
Stools,   in   gastric   cancer,  185 ;  catarrh, 
328  ;  dilatation,  145  ;  dyspepsia  ner- 
vosa, 445  ;  phlegmon,  305  ;  ulcer,  246. 

in  stricture  of  cardia,  74. 

lienteric,  186,  250. 

tarry,  247. 
Storer,  205. 
Striimpell,  119. 
Substances,  mucinogenous,  287. 

pepsinogenous,  286. 

peptogenous,  341, 

zymogenous,  226. 
Sugar,  digestion  of,  49. 


496 


DISEASES   OP  THE  STOMACH. 


Surgery  of  stomach,  157. 
Swieton,  Van,  166. 
Switzer,  97. 
Symonds,  97. 

Sympathetic  nerve,  course  of,  367. 
Syntonin,  demonstration   and   reactions 
of,  42. 

Tabes,  gastric  crises  in,  403,  443,  472. 

Talamon-Balzer,  242. 

Talma,  327,  417,  454. 

Taste  in  gastric  cancer,  178  ;  ulcer,  243  ; 
gastritis  catarrhalis  chronica,  326 ; 
in  rumination,  430. 

Teeth,  care  of,  in  diseases  of  stomach, 
346. 

Telangiectatic  carcinoma  of  stomach, 
170. 

Test-breakfast,  17. 
-dinner,  19. 
-meal,  19. 

Tetany  after  washing  out  stomach,  361. 
in  gastric  dilatation,  146. 

Thaddeus,  83. 

Thiersch,  167,  188. 

Thomas,  461. 

Thrombosis  in  gastric  cancer,  176. 

Tiedemann,  15. 

Titration,  method  of,  22. 

Todd,  313,  390,  414. 

Tolma,  222,  225. 

Tongue  in  diseases  of  stomach,  297. 
in  gastric  cancer,  178;  catarrh,  acute, 
295  ;  chronic,  326  ;  dilatation,  137  ; 
hypersecretion  of  gastric  juice,  417 ; 
neurasthenia,  440 ;  ulcer,  243  ;  phleg- 
monous gastritis,  306 ;  stricture  of 
cardia,  74. 

Torminfe  ventriculi,  425. 

Transformation  of  gastric  ulcer  into  can- 
cer, 259. 
of  starch,  41. 

Traube,  132,  245. 

Trendelenburg,  108. 

Trier,  265. 

Trinkler,  417. 

Troisier,  176. 

Tropajolin,  23. 

Trousseau,  331,  355,  414. 

TschelzofE,  344. 

Tube,  Faucher's,  6. 
stomach,   4 ;    dangers  of,  14,  84,  260, 
361 ;   use   of,   in   chronic   gastritis ; 


neuroses,  452;    ulcer,    266;    tympa- 
nites, 421. 
Tuberculosis,   condition   of  stomach  in, 

464. 
Tuckwell,  423. 
Tiingel,  171. 
TLipfelmethode,  22. 
Tumor  in  gastric  cancer,  180,  185. 

hypertrophy  of  muscularis  at  pylorus, 

"  200,  205. 
mediastinal,  83. 
retroperitoneal,  83. 
Tumors,  non-carcinomatous,  of  stomach, 

215. 
Tympanites,  420. 

Typhoid  fevei",  condition  of  stomach  in, 
464. 

Uflelmann,  26,  33,  292. 

Ulcer  of  duodenum,  232,  264. 

Ulcer  of  stomach,  follicular,  223,  402. 
round,  217;  age  in,  234:  anatomical 
characters  of,  239 ;  bloody  stools  in, 
246 ;  cicatrization  of,  240 ;  composi- 
tion of  blood  in,  229;  diagnosis  of, 
206,  254,  262;  diet  in,'268;  etiology, 
220;  excision  of,  274;  fistulfe  in, 
252  ;  hasmorrhage  in,  245  ;  treatment 
of,  273 ;  hyperacidity  of  gastric  juice 
in,  229 ;  in  cutaneous  burns,  232 ; 
micro-organisms  in,  232 ;  occurrence, 
233 ;  operative  procedures  in,  274 ; 
pain  in,  243;  treatment  of,  272; 
pathological  anatomy,  235  ;  perfora- 
tion of,  249 ;  perforation-peritonitis, 
251;  treatment  of,  274;  prognosis, 
265 ;  relapsing,  228 ;  rest-cure  in, 
266 ;  site  of,  239,  263 ;  sounding  of 
stomach  in,  260 ;  stools  in,  243 ; 
symptoms  of,  242 ;  treatment  of 
266 ;  at  mineral  springs,  275 ;  use  of 
Carlsbader  water  in,  267,  275  ;  use  of 
iron  in,  269. 
syphilitic,  241,  253. 
tubercular,  242,  254. 

Ultramarine,  29. 

Unrest  of  stomach,  antiperistaltic,  426. 
peristaltic,  145,  425. 

Vagus,  course  of,  366. 
Value  of  chemical  tests,  475. 
Vanillin,  phloroglucin,  39. 
Vanni,  225. 


INDEX. 


49: 


Vaso-motor  nerves  of  stomach,  371  ;  re- 
lations of,  in  gastric  secretion,  oTl. 
Vassale,  221. 
Velden,  Von  den,  50,  70,  111,  187, 188, 190, 

414,  417. 
Verneuil,  108. 
Vert  brillant,  25. 
Vertigo  gyrosa,  321. 

stomaohalis,  331. 

e  stomacho  laeso,  331. 
Vidal,  232. 

Villous  carcinoma  of  stomach,  170. 
Violet,  methyl,  25. 
Virchow,  Ii.,"ll7. 
Virchow,  R.,  86,  176,  200,  237,  253,  292, 

309. 
Visceral  neuralgia,  442. 
Vizioli,  453. 
Vogel,  208. 
Vormagen,  72. 
Vomit,  coffee-grounds,  179. 

taste  of,  295,  445. 
Vomiting,  376. 

hysterical,  423. 

in  abscess  of  liver,  448. 

in  diseases"  of  brain,  448 ;  spinal  cord, 
448. 

in  gastric  cancer,  211  ;  catarrh,  acute, 
295  ;  chronic,  327 ;  dilatation,  137 ; 
iilcer,  245. 

in  hypersesthesia  of  stomach,  392. 

in  injuries  to  uterus,  449. 

in  neurasthenia,  424,  444. 

in  opei'ations  on  bladder,  449  ;  urethra, 
449. 

in  phlegmonous  gastritis,  305. 

in  phthisis,  464. 

in  poisoning,  310. 

in  pregnancy,  448. 

in  renal  abscess,  448 ;  colic,  448 ;  dis- 
eases, 471. 

in  sea-sickness,  448. 

in  stricture  of  cardia,  72. 

nervous,  421. 

of  blood.      See  HyEMATEMESIS. 

periodical,  424, 
reflex,  423. 


Wagner,  115. 

Waldeyer,  167,  169. 

Walshe,  162,  166,  255. 

Washing  of  stomach,  63,  154,  343. 

in  poisoning,  311. 
Water,  filling  stomach  with,  61. 
Watson,  278. 

Weighing,  systematic,  460. 
Weiss,  5. 
Weissgerber,  419. 
Welch,  6,  162,  163,   170,  171,   216,  233, 

239,  250,  253,  279,  335. 
Werner,  140,  473. 
West,  250. 
Westphal,  331. 
Westphalen,  336. 
Wiederhofer,  136,  334. 
Wiesner,  14. 
Wilkens,  415. 
Wilkinson,  162. 
Wilks,  232. 
Williams,  242. 
Willigk,  265. 
Wilson,  378. 
Windthier,  431. 
Winkhaus,  148. 
Winter,  40. 
Winternitz,  157. 
Wirbelweh,  405. 
Witosowski,  237,  238. 
Witte,  246. 
Wolff,  J.,  479. 
Wolff,  L.,  53,  153. 
Wolfram,  189. 
Wiirzburg,  163. 

Yeast-cells  in  stomach-contents,  308. 
Yellowly,  277. 
Yeo,  Burney,  474. 

Zabludowski,  147,  156. 

Zeckendorf,  435. 

Zenker,  61,  63,  73. 

Zesas,  101. 

Ziegler,  304. 

Ziemssen,  Von,  14,  59,  67,  68,  72,  110,  111, 

117,  366,  457. 
Zinc,  sulphide  of,  29. 


THE    END. 


December,  1892. 

MEDICAL 

AND 

HYGIENIC    WOEKS 


PUBLISHED   BY 


D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street,  New  York. 


AULDE  (JOHN).  The  Pocket  Pharmacy,  with  Therapeutic  Index.  A  resume 
of  the  CHnical  Applications  of  Remedies  adapted  to  the  Pocket-case,  for 
the  Treatment  of  Emergencies  and  Acute  Diseases.     12mo.     Cloth,  $2.00. 

BARKER  (FORDYCE).  On  Sea-Sickness.  A  Popular  Treatise  for  Travelers 
and  the  General  Reader.     Small  12mo.     Cloth,  75  cents. 

BARKER  (FORDYCE).  On  Puerperal  Disease.  Clinical  Lectures  delivered  at 
Bellevue  Hospital.  A  Course  of  Lectures  valuable  alike  to  the  Student  and 
the  Practitioner.     Third  edition.     8vo.     Cloth,  $5.00;  sheep,  $6.00. 

BARTHOLOW  (ROBERTS).  A  Treatise  on  Materia  Medica  and  Therapeutics. 
Seyenth  edition.  Revised,  enlarged,  and  adapted  to  "  The  New  Pharmacopoeia." 
8vo.     Cloth,  $5.00;  sheep,  $6.00. 

BARTHOLOW  (ROBERTS).  A  Treatise  on  the  Practice  of  Medicine,  for  the 
Use  of  Students  and  Practitioners.  Sixth  edition,  revised  and  enlarged.  8vo. 
Cloth,  $5.00;  sheep,  $6.00. 

BARTHOLOW  (ROBERTS).  On  the  Antagonism  between  Medicines  and  be- 
tween Remedies  and  Diseases.  Being  the  Cartwright  Lectures  for  the  Year 
1880.     8vo.     Cloth,  $L25. 

BILLINGS  (F.  S.).  The  Relation  of  Animal  Diseases  to  the  Public  Health,  and 
their  Prevention.     8vo.     Cloth,  $4.00. 

BILLROTH  (THEODOR).  General  Surgical  Pathology  and  Therapeutics.  A 
Text-Book  for  Students  and  Physicians.  Translated  from  the  tenth  German 
edition,  by  special  permission  of  the  author,  by  Charles  E.  Hackley,  M.  D. 
Fifth  American  edition,  revised  and  enlarged.     8vo.     Cloth,  $5.00;  sheep,  $6.00. 

BOYCE  (RUBERT).  A  Text-Book  of  Morbid  Histology.  For  Students  and 
Practitioners.     With  180  Colored  Illustrations.     Cloth,  $T.50. 

BRAMWELL  (BYROM).  Diseases  of  the  Heart  and  Thoracic  Aorta.  Illus- 
trated with  226  Wood-Eng^ravings  and  68  Lithograph  Plates — showing  91 
Figures— in  all  317  Illustrations.     8vo.     Cloth,  $8.00;  sheep,  $9.00. 

BRYANT  (JOSEPH  D.).  A  Manual  of  Operative  Surgery.  New  edition,  revised 
and  enlarged.     793  Illustrations.     8vo.     Cloth,  $5.00  ;  sheep,  $6.00 

BUCK.  (GURDON).  Contributions  to  Reparative  Surgery,  showing  its  Applica- 
tion to  the  Treatment  of  Deformities  produced  by  Destructive  Disease  or 
Injury;  Congenital  Defects  from  Arrest  or  Excess  of  Development;  and 
Cicatricial  Contractions  following  Burns.  Illustrated  by  Thirty  Cases  and 
fine  Engravings.     8vo.     Cloth,  $3.00, 


2 

CAMPBELL  (F.  E.).  The  Language  of  Medicine.  A  Mannal  giving  the  Origin, 
Etymology,  Pronunciation,  and  Meaning  of  the  Technical  Terms  found  in 
Medical  Literature.     8vo.     Cloth,  |3.00. 

CASTRO  (D'OLIVEIRA).  Elements  of  Therapeutics  and  Practice  according 
to  the  Dosimetric  System.     8vo.     Cloth,  $4.00. 

CHAUVEAU  (A.)  The  Comparative  Anatomy  of  the  Domesticated  Animals. 
By  A.  Chauveau,  M.  D.,  LL.  D.,  Member  of  the  Institute  (Academy  oi 
Sciences);  Inspector-General  of  Veterinary  Schools  in  France ;  Professor 
at  the  Museum  of  Natural  History,  Paris.  Revised  and  enlarged,  with  the 
co-operation  of  S.  Arloing,  Director  of  the  Lyons  Veterinary  School ;  Pro- 
fessor of  Experimental  and  Comparative  Medicine  at  the  Lyons  Faculty  ot 
Medicine.  Second  English  edition.  Translated  and  edited  by  George  Flem- 
ing, C.  B.,  LL.  D.,  F.  R.  C.  V.  S.,  late  Principal  Veterinary  Surgeon  of  the 
British  Army ;  Foreign  Corresponding  Member  of  the  Societe  Royale  de 
M6decine,  and  of  the  Societe  Royale  de  Medicine  Publique,  of  Belgium,  etc. 
8vo,  with  585  Illustrations.     Cloth,  $7.00. 

CORNING  (J.  L.).  Brain  Exhaustion,  with  some  Preliminary  Considerations 
on  Cerebral  Dynamics.     Crown  8vo.     Cloth,  $2.00. 

CORNING  (J.  L.).  Local  Anaesthesia  in  General  Medicine  and  Surgery.  Being 
the  Practical  Application  of  the  Author's  Recent  Discoveries.  With  Illus- 
trations.    Small  8vo.     Cloth,  $1.25. 

DAVIDSON  (ANDREW).  Geographical  Pathology:  An  Inquiry  into  the 
Geographical  Distribution  of  Infective  and  Climatic  Diseases.  2  vols. 
8vo.     Cloth,  $7.00. 

DEXTER  (FRANKLIN).  The  Anatomy  of  the  Peritonteum.  12mo.  With 
39  colored  Illustrations.     {In  press?) 

DOTY  (ALVAH  H,).  A  Manual  of  Instruction  in  the  Principles  of  Prompt 
Aid  to  the  Injured.  Designed  for  Military  and  Civil  Use.  96  Illustrations. 
12mo.    Cloth,  $1.25. 

ELLIOT  (GEORGE  T.).  Obstetric  Clinic :  A  Practical  Contribution  to  the  Study 
of  Obstetrics  and  the  Diseases  of  Women  and  Children.    8vo.    Cloth,  $4.50. 

EVANS  (GEORGE  A.).  Hand-Book  of  Historical  and  Geographical  Phthisi- 
ology.  With  Special  Reference  to  the  Distribution  of  Consumption  in  the 
Lnited  States.     8vo.     Cloth,  $2.00. 

EWALD  (C.  A.).  Lectures  on  the  Diseases  of  the  Stomach.  By  Dr.  C.  A. 
Ewald,  Professor  of  Pathology  and  Therapeutics  in  the  University  of  Berlin, 
etc.  Translated  from  the  German  by  special  permission  of  the  author,  by 
Morris  Manges,  A.  M.,  M.  D.     Cloth,  $5.00  ;  sheep,  $6.00. 

FLINT  (AUSTIN).  Medical  Ethics  and  Etiquette.  Commentaries  on  the 
National  Code  of  Ethics.     12mo.     Cloth,  60  cents. 

FLINT  (AUSTIN).  Medicine  of  the  Future.  An  Address  prepared  for  the 
Annual  Meeting  of  the  British  Medical  Association  in  1886.  With  Portrait 
of  Dr.  Flint.     12mo.     Cloth,  $1.00. 

FLINT  (AUSTIN,  .Jr.).  Text-Book  of  Human  Physiology;  designed  for  the 
Use  of  Practitioners  and  Students  of  Medicine.  Illustrated  with  three 
hundred   and   sixteen  Woodcuts  aod  Two  Plates.      Fourth  edition,  revised. 

Imperial  8yo.     Cloth,  $6.00;  sheep,  $7.00. 

FLINT  (AUSTIN,  Jr.).  The  Physiological  Efiects  of  Severe  and  Protracted 
Muscular  Exercise ;  with  Special  Reference  to  its  Influence  upon  the  Excre- 
tion of  Nitrogen.     12mo.     Cloth,  $1.00. 

FLINT  (AUSTIN,  Jr.).  The  Source  of  Muscular  Power.  Arguments  and  Con- 
clusions drawn  from  Observation  upon  the  Human  Subject  under  Conditions 
of  Rest  and  of  Muscular  Exercise.     12mo.     Cloth,  $1.00. 


FLINT  (AUSTIN,  Jr.).     Physiology  of  Mau.     Designed  to  represent  the  Exist- 
ing State  of  Pliysiological  Science  as  applied  to  the  Functions  of  the  Human 
Body,     Complete  in  5  vols.,  8vo.     Per  vol.,  cloth,  $4.50;  sheep,  $5.50. 
*^*  Vols.  I  and  II  can  be  had  in  cloth  and  sheep  binding;  Vol.  Ill  in  sheep 
only.     Vol.  IV  is  at  present  out  of  print. 

FLINT  (AUSTIN,  Je.).  Manual  of  Chemical  Examinations  of  the  Urine  in 
Disease ;  with  Brief  Directions  for  the  Examination  of  the  most  Common 
Varieties  of  Urinary  Calculi.     Revised  edition.     12mo.     Cloth,  $1.00. 

FOSTER  (FRANK  P.).  Illustrated  Encyclopaedic  Medical  Dictionary,  being 
a  Dictionary  of  the  Technical  Terms  used  by  Writers  on  Medicine  and  the 
Collateral  Sciences  in  the  Latin,  Enghsh,  French,  and  German  Languages. 
This  work  will  be  completed  in  four  volumes.  (Sold  only  iy  suiscription.) 
The  work  will  consist  of  Four  Volumes,  and  will  be  sold  in  Parts;  Three 
Parts  to  a  Volume.     Nine  Parts  are  now  ready  for  delivery. 

FOURNIER  (ALFRED).  Syphilis  and  Marriage.  Translated  bv  P.  Albert 
Morrow,  M.  D.     8vo.     Cloth,  $2.00;  sheep,  $3.00. 

FREY  (HEINRICH).  The  Histology  and  Histochemistry  of  Man.  A  Tj'eatise 
on  the  Elements  of  Composition  and  Structure  of  the  Human  Body.  Trans- 
lated from  the  fourth  German  edition  by  Arthur  E.  .J.  Barker,  M.  D.,  and 
revised  by  the  author.  With  608  Engravings  on  Wood.  8vo.  Cloth,  $5.00  ; 
sheep,  $6.00. 

FRIEDLANDER  (CARL).  The  Use  of  the  Microscope  in  Clinical  and  Patho- 
logical Examinations.  Second  edition,  enlarged  and  improved,  with  a 
Chromo-lithograph  Plate.  Translated,  with  the  permission  of  the  author, 
by  Henry  0.  Coe,  M.  D.     8vo.     Cloth,  $1.00. 

FUCHS  (ERNEST).  Text-Book  of  Ophthalmology.  By  Dr.  Ernest  Fuchs, 
Professor  of  Ophthalmology  in  the  University  of  Vienna.  With  178  Wood- 
cuts. Authorized  translation  from  the  second  enlarged  and  improved  Ger- 
man edition,  by  A.  Duane,  M.  D.     Cloth,  $5.00;  sheep,  $6.00. 

GARMANY  (.JASPER  J.).  Operative  Surgery  on  the  Cadaver.  With  Two 
Colored  Diagrams  showing  the  Collateral  Circulation  after  Ligatures  of 
Arteries  of  Arm,  Abdomen,  and  Lower  Extremity.  Small  8vo.  Cloth, 
$2.00. 

GERSTER  (ARPAD  G.).  The  Rules  of  Aseptic  and  Antiseptic  Surgery. 
A  Practical  Treatise  for  the  Use  of  Students  and  the  General  Practitioner. 
Illustrated  with  over  two  hundred  tine  Engravings.  8vo.  Cloth,  $5.00  ; 
sheep,  $6.00. 

GIBSON-RUSSELL.  Physical  Diagnosis :  A  Guide  to  Methods  of  Clinical  In- 
vestigation. By  G.  A.  Gibson,  M.  D.,  and  William  Russell.  M.D.  With 
101  Illustrations.     12mo.     (Studext's  Seeies.)     Cloth,  $2.50. 

GOULET  (JOHN  W.  S.).  Diseases  of  the  Urinary  Apparatus.  Part  L  Phleg- 
raasic  Affections.  Being  a  Series  of  Twelve  Lectures  delivered  during  the 
autumn  of  1891.  With  an  Addendum  on  Retention  of  Urine  from  Pros- 
tatic Obstruction  in  Elderly  Men.     Cloth.  $1.50. 

GROSS  (SAMUEL  W.).  A  Practical  Treatise  on  Tumors  of  the  Mammary 
Gland.     Illustrated.     8vo.     Cloth,  $2.50. 

GRUBER  (JOSEF).  A  Text-Book  of  the  Diseases  of  the  Ear.  Translated 
from  the  second  German  edition  by  special  permission  of  the  author,  and 
edited  by  Edward  Law,  M.  D.,  and  Coleman  Jewell,  M.  D.  With  150  Illus- 
trations and  70  Colored  Figures  on  Two  Lithoarraphic  Plates.  8vo.  Cloth, 
$5.00. 

GUTMANN  (EDWARD).  The  Watering-Places  and  Mineral  Springs  of  Ger- 
many, Austria,  and  Switzerland.     Illustrated.     12mo.     Cloth,  $2.50. 


HAMMOND  (W.  A.).  A  Treatise  on  Diseases  of  the  !N'ervous  System.  With 
the  Collaboration  of  Graeme  M.  Hammond,  M.  D.  With  One  Hundred  and 
Eighteen  Illustrations.  Ninth  edition,  with  corrections  and  additions.  8vo. 
Cloth,  $5.00 ;  sheep,  $6.00. 

HAMMOND  (W.  A.).  A  Treatise  on  Insanity,  in  its  Medical  Relations.  8vo. 
Cloth,  $5.00;  sheep,  $6.00. 

HAMMOND  (W.  A.).  Clinical  Lectures  on  Diseases  of  the  Nervous  System. 
Delivered  at  Bellevue  Hospital  Medical  College.  Edited  by  T.  M.  B.  Cross, 
M.  D.     8vo.     Cloth,  $3.50. 

HARVEY  (A.).     First  Lines  of  Therapeutics.     12mo.     Cloth,  $1.50. 

HOFFMANN-ULTZMANN.  Analysis  of  the  Urine,  with  Special  Reference 
to  Diseases  of  the  Urinary  Apparatus.  By  M.  B.  Hoffmann,  Professor  in 
the  University  of  Gratz;  and  R.  Ultzmann,  Tutor  in  the  University  of 
Vienna.     Tliird  edition,  revised  and  enlarged.     Svo.     Cloth,  $2.00. 

HIRT  (LUDWIG).  The  Pathology  and  Therapeutics  of  Nervous  Diseases.  For 
Physicians  and  Students.  By  Dr.  Ludwig  Hirt,  Pnjfessor  at  the  University 
of  Breslau.  Translated  by  Aug.  Hoch,  M.  D.,  Assistant  Physician  to  the 
Johns  Hopkins  Hospital.  With  an  Introduction  by  William  Osier,  M.  D., 
Professor  of  Medicine  in  the  Johns  Hopkins  University,  and  Physician-in- 
Chief  to  the  Johns  Hopkins  Hospital,  Baltimore.  With  Illustrations.  {In 
preparation.) 

HOWE  (JOSEPH  W.).  Emergencies,  and  how  to  treat  them.  Fourth  edition, 
revised.     Svo.     Cloth,  $2.50. 

HOWE  (JOSEPH  W.).  The  Breath,  and  the  Diseases  which  give  it  a  Fetid 
Odor.  With  Directions  for  Treatment.  Second  edition,  revised  and  corrected. 
12mo.     Cloth,  $1.00. 

HUEPPE  (FERDINAND).  The  Methods  of  Bacteriological  Investigation. 
Written  at  the  request  of  Dr.  Robert  Koch.  Translated  by  Hermann  M. 
Biggs,  M.D.     Illustrated.     Svo.     Cloth,  $2.50. 

JACCOUD  (S.).  The  Curability  and  Treatment  of  Pulmonary  Phthisis.  Trans- 
lated and  edited  by  Montagu  Lubbock,  M.  D.     Svo.     Cloth,  $4.00. 

JOHNSTONE  (ALEX.).  Botany  :  A  Concise  Manual  for  Students  of  Medicine 
and  Science.  With  164  Illustrations  and  a  Series  of  Floral  Diagrams. 
12mo.     (Student's  Seeies.)     Cloth,  $1.75. 

JONES  (H.  MACNAUGHTON).  Practical  Manual  of  Diseases  of  Women  and 
Uterine  Therapeutics.  For  Students  and  Practitioners.  188  Illustrations. 
12mo.     Cloth,  $3.00, 

JOURNAL  OF  CUTANEOUS  AND  GENITO-URINARY  DISEASES. 
Published  Monthly.  Edited  by  John  A.  Fordyce,  M.  D.  Terras,  $2.50  per 
annum. 

KEYES  (E  L.).  A  Practical  Treatise  on  Genito-Urinary  Diseases,  including 
Syphilis.  Being  a  new  edition  of  a  work  with  the  same  title,  by  Van  Buren 
and  Keyes.  Almost  entirely  rewritten.  Svo.  With  Illustrations.  Cloth, 
$5.00;  sheep,  $6.00. 

KEYES  (E.  L.).  The  Tonic  Treatment  of  Syphilis,  including  Local  Treatment 
of  Lesions.     Svo.     Cloth,  $1.00. 

KINGSLEY  (N.  W.).  A  Treatise  on  Oral  Deformities  as  a  Branch  of  Mechani- 
cal Surgery.    With  over  350  Illustrations.    Svo.    Cloth,  $5.00;  sheep,  $6.00. 


LEGG  (J.  WIOKHAM).  On  the  Bile,  Jaundice,  and  Bilious  Diseases.  With 
Illustrations  in  Ohromo-Lithography.     8vo.      Cloth,  $6.00 ;  sheep,  $7.00. 

LITTLE  (W.  J.).     Medical  and  Surgical  Aspects  of  In-Knee  (Genu- Valgum^ 
its  Relation  to  Rickets,  its  Pi-evention,  and  its  Treatment,  with  and  without 
Surgical  Operation.     Illustrated  by  upward  of  Fifty  Figures  and  Diagrams. 
8vo.     Cloth,  $2.00. 

LORING  (EDWARD  G.).     A  Text-Book  of  Ophthalmoscopy. 

Part  I.  The  Normal  Eye,  Determination  of  Refraction,  and  Diseases  of  the 
Media.  With  131  Illustrations,  and  4  Chromo-Lithographs.  8vo.  Buck- 
ram, $5.00. 

Part  II.  Diseases  of  the  Retina,  Optic  Nerve,  and  Choroid :  their  Varie- 
ties and  Complications.  The  manuscript  of  this  volume,  which  the 
author  finished  just  prior  to  his  death,  has  been  thoroughly  edited  and 
revised  by  F.  B.  Loring,  M.D.,  of  Washington,  D.  C,  and  is  now  issued 
in  the  same  style  as  the  first  volume.  Profusely  illustrated.  Part  11, 
buckram,  $5.00.     Two  Parts,  buckram,  $10.00. 

LUSK  (WILLIAM  T.).  The  Science  and  Art  of  Midwifery.  With  246  Illustra- 
tions.    Fourth  edition,  revised  and  enlarged.     8vo.     Cloth,  $5.00 ;  sheep,  $6.00'" 

MARCY  (HENRY  O.).  The  Anatomy  and  Surgical  Treatment  of  Hernia. 
4to,  with  about  Sixty  full-page  Heliotype  and  Lithographic  Reproductions 
from  the  Old  Masters,  and  numerous  Illustrations  in  the  Text.  (Sold  only 
'by  siibscription.) 

MARKOE  (T.  M.).  A  Treatise  on  Diseases  ot  the  Bones.  With  Illustrations. 
8vo.     Cloth,  $4.50. 

MATHEWS  (JOSEPH  M.).  A  Treatise  on  Diseases  of  the  Rectum,  Anus, 
and  Sigmoid  Flexure.  8vo.  With  Six  Chromo-lithographs,  and  Illustra- 
tions in  the  text.     {Sold  only  ty  siibscription.) 

MILLS  (WESLEY).  A  Text-Book  of  Animal  Physiology,  with  Introductory 
Chapters  on  General  Biology  and  a  full  Treatment  of  Reproduction  for 
Students  of  Human  and  Comparative  Medicine,  8vo,  With  505  Illustra- 
tions,    Cloth,  $5.00;  sheep,  $6.00. 

MILLS  (WESLEY).  A  Text-Book  of  Comparative  Physiology.  For  Students 
and  Practitioners  of  Veterinary  Medicine.     Small  8vo.     Cloth,  $3,00. 

THE   NEW   YORK   MEDICAL   JOURNAL    (weekly).     Edited  by  Frank  P 
Foster,  M.  D.     Terms,  $5.00  per  annum. 
Binding  Cases,  cloth,  50  cents  each. 

"Self- Binder"  (this  is  used  for  temporary  binding  only),  90  cents. 
General  Index,  from  April,  1865,  to  June,  18T6  (23  vols.)    8vo.    Cloth,  75  cts. 

NIEMEYER  (FELIX  VON).  A  Text-Book  of  Practical  Medicine,  with  particu- 
lar reference  to  Physiology  and  Pathological  Anatomy.  Containing  all  the 
author's  Additions  and  Revisions  in  the  eighth  and  last  German  edition. 
Translated  by  George  H.  Humphreys,  M.  D,,  and  Charles  E.  Hackley,  M.  D. 
2  vols.,  8vo.     Cloth,  $9.00;  sheep,  $11.00. 

NIGHTINGALE'S  (FLORENCE)  Notes  on  Nursing.     12mo.     Cloth,  76  cents. 

OSLER  (WILLIAM).  The  Principles  and  Practice  of  Medicine.  Designed  for 
the  Use  of  Practitioners  and  Students  of  Medicine.  Sold  only  by  subscrip- 
tion.    Cloth,  $5.50 ;  sheep,  $6.50  ;  half  morocco,  $7.00. 


PELLEW  (0,  E.).  A  Manual  of  Practical  Medical  Chemistry.  12mo.  With 
Illustrations.     {In  press.) 

PEREIRA'S  (Dr.)  Elements  of  Materia  Medica  and  Therapeutics.  Abridged 
and  adapted  for  the  Use  of  Medical  and  Pharmaceutical  Practitioners  and 
Students,  and  comprising  all  the  Medicines  of  the  British  Pharmacopoeia, 
with  such  others  as  are  frequently  ordered  in  Prescriptions,  or  required  by 
the  Physician.  Edited  by  Robert  Bentley  and  Theophilus  Redwood.  Royal 
8vo.     Cloth,  $7.00 ;  sheep,  $8.00. 

PEYER  (ALEXANDER).  An  Atlas  of  Clinical  Microscopy.  Translated  and 
edited  by  Alfred  C.  Girard,  M.  D.  First  American,  from  the  manuscript 
of  the  second  German  edition,  with  Additions.  Ninety  Plates,  with  105 
Illustrations,  Ohromo-Lithographs.         Square  8vo.     Cloth,  $6.00. 

PIFFARD  (HENRY  G.).  A  Practical  Treatise  on  Diseases  of  the  Skin.  By 
Henry  G.  Piftard,  A.  M.  M.  D.,  assisted  by  Robert  M.  Fuller,  M.  D.  With 
Fifty  full-page  Original  Plates  and  Thirty-three  Illustrations  in  the  Text. 
4to.     {Sold  only  hy  subscription.) 

POMEROY  (OREN  D.).  The  Diagnosis  and  Treatment  of  Diseases  of  the  Ear. 
With  One  Hundred  Illustrations.  Second  edition,  revised  and  enlarged.  8vo. 
Cloth,  $3.00. 

POORE  (C.  T.).  Osteotomy  and  Osteoclasis,  for  the  Correction  of  Deformities 
of  the  Lower  Limbs.     50  Illustrations.     8vo.     Cloth,  $2.50. 

QUAIN  (RICHARD).  A  Dictionary  of  Medicine,  including  General  Pathology, 
General  Therapeutics,  Hygiene,  and  the  Diseases  peculiar  to  Women  and 
Children.  By  Various  Writers.  Edited  by  Richard  Quain,  M.  D.,  In  one 
large  8vo  volume,  with  complete  Index,  and  138  Illustrations.  {Sold  only 
hy  subscription.) 

RANNEY  (AMBROSE  L.).  Applied  Anatomy  of  the  Nervous  System,  being  a 
Study  of  this  Portion  of  the  Human  Body  from  a  Standpoint  of  its  General 
Interest  and  Practical  Utility,  designed  for  Use  as  a  Text-Book  and  as  a  Work 
of  Reference.  Second  edition,  revised  and  enlarged.  Profusely  illustrated.  8vo. 
Cloth,  $5.00;  sheep,  $6.00. 

ROBINSON  (A.  R.).  A  Manual  of  Dermatology.  Revised  and  corrected.  8vo. 
Cloth,  $5.00. 

ROSCOE-SCHORLEMMER.     Treatise  on  Chemistry. 

Vol.  1.  Non-Metallic  Elements.     8vo.     Cloth,  $5.00. 

Vol.  2.  Part    I.    Metals.     8vo.     Cloth,  $3.00. 

Vol.  2.  Part  II.    Metals.     8vo.     Cloth,  $3.00. 

Vol.  3.  Part  I.  The  Chemistry  of  the  Hydrocarbons  and  their  Derivatives. 
8vo.     Cloth,  $5.00. 

Vol.  3.  Part  II.  The  Chemistry  of  the  Hydrocarbons  and  their  Derivatives. 
Svo.     Cloth,  $5.00. 

Vol.  3.  Part  III.  The  Chemistry  of  the  Hydrocarbons  and  their  Deriva- 
tives.    Svo.     Cloth,  $3.00. 

Vol.  3.  Part  IV.  The  Chemistry  of  the  Hydrocarbons  and  tlieir  Deriva- 
tives.    Svo.     Cloth,  $3.00. 

VoL  3.  Part  V.  The  Chemistry  of  the  Hydrocarbons  and  their  Deriva- 
tives.    Svo.     Cloth,  $3.00. 

ROSENTHAL  (I.).  General  Physiology  of  Muscles  and  Nerves.  With  75  Wood- 
cuts.    12mo.     Cloth,  $1.50. 


SAYRE  (LEWIS  A.)-  Practical  Manual  of  tlie  Treatment  of  Club-Foot.  Fonrtb 
edition,  enlarged  aud  corrected.     12mo.     Cloth,  $1.25. 

SAYRE  (LEWIS  A.).  Lectures  on  Orthopedic  Surgery  and  Diseases  of  the 
Joints,  delivered  at  Bellevue  Hospital  Medical  College.  New  edition,  illus- 
trated with  824  Engravings  on  Wood.     8vo.     Cloth,  $5.00  ;  sheep,  $6.00. 

SCHULTZE  (B.  S.).  The  Pathology  and  Treatment  of  Displacements  of  the 
Uterus.  Translated  from  the  German  by  Jameson  J.  Macan,  M.  A.,  etc.; 
and  edited  by  Arthur  V.  Macan,  M.  B.,  etc.  With  One  Hundred  and 
Twenty  Illustrations.     8vo.     Cloth,  $3.50. 

SHIELD  (A.  MARMADUKE).  Surgical  Anatomy  for  Students.  12mo. 
(Student's  Series.)     Cloth,  $1.75. 

SHOEMAKER  (JOHN  V.).  A  Text-Book  of  Diseases  of  the  Skin.  Six 
Chromo-Lithographs  and  numerous  Engravings.  Second  edition,  revised 
and  enlarged.     8vo.     Cloth,  $5.00  ;  sheep,  $6.00. 

SIMPSON  (JAMES  Y.).  Selected  Works:  Anassthosia,  Diseases  of  Women. 
3  vols.,  8vo.     Per  volume.     Cloth,  $3.00;  sheep,  $4.00. 

SIMS  (J.  MARION).  The  Story  of  my  Life.  Edited  by  his  Son,  H.  Marion 
Sims,  M.  D.     With  Portrait.     12mo.     Cloth,  $LoO. 

SKENE  (ALEXANDER  J.  C).  A  Text-Book  on  the  Diseases  of  Women. 
Illustrated  with  two  hundred  and  fifty-four  Illustrations,  of  which  one 
hundred  and  sixty-five  are  original,  and  nine  chromo-lithographs.  Second 
edition.     8vo.     {Sold  only  hy  suiseription.) 

STEINER  (JOHANNES).  Compendium  of  Children's  Diseases :  a  Hand-Book 
for  Practitioners  and  Students.  Translated  from  the  second  German  edition, 
by  Law  son  Tait.     8vo.     Cloth,  $3.50;  sheep,  $4.50. 

STEVENS  (GEORGE  T.)  Functional  Nervous  Diseases:  their  Causes  and 
theii  Treatment.  Memoir  for  the  Concourse  of  1881-1883,  Academic  Royal 
de  M6decine  de  Belgique.  With  a  Supplement,  on  the  Anomalies  of  Re- 
fraction and  Accommodation  of  the  Eye,  and  of  the  Ocular  Muscles.  Small 
8vo.    With  six  Photographic  Plates  and  twelve  Illustrations.    Cloth,  $2.50. 

STONE  (R.  FRENCH).  Elements  of  Modern  Medicine,  including  Principles  of 
Pathology  and  of  Therapeutics,  with  many  Useful  Memoranda  and  Valuable 
Tables  of  Reference.  Accompanied  by  Pocket  Fever  Charts.  Designed  for 
the  Use  of  Students  and  Practitioners  of  Medicine.  In  wallet-book  form, 
with  pockets  on  each  cover  for  Memoranda,  Temperature  Charts,  etc. 
Roan,  tuck,  $2.50. 

STRECKER  (ADOLPH).  Short  Text-Book  ot  Organic  Chemistry.  By  Dr. 
Johannes  Wislicenus.  Translated  and  edited,  with  Extensive  Additions,  by 
W.  H.  Hodgkinson  and  A.  J.  Greenaway.     8vo.     Cloth,  $5.00. 

STRtJMPELL  (ADOLPH).  A  Text-Book  of  Medicine,  for  Students  and  Prac- 
titioners.    With  111  Illustrations.     Svo.     Cloth,  $6.00 ;  sheep,  $7.00. 

THOMAS  (T.  GAILLARD).  Abortion  and  its  Treatment,  from  the  Stand- 
point of  Practical  Experience.  A  Special  Course  of  Lectures  delivered  be- 
fore the  College  of  Physicians  and  Surgeons,  New  York,  Session  of  1889-'90. 
From  Notes  by  P.  Brynberg  Porter,  M.  D.  Revised  by  the  Author. 
12mo.      Cloth,  $1.00. 


THOMSON  (J.  ARTHUR).     Outlines  of  Zoology.     With  TLirty-two  full-page 
niustrations.     12mo.     Cloth,  $3.00. 

TRACY  (ROGER  S.).  The  Essentials  of  Anatomy,  Physiology,  and  Hygiene. 
12mo.     Cloth.  $1.25. 

TRANSACTIONS  OF  THE  NEW  YORK  STATE  MEDICAL  ASSOCIA- 
TION, VOLS.  I  and  II.  Being  the  Proceedings  of  the  First  Annual  Meet- 
ing of  the  New  York  State  Medical  Association,  held  in  New  York,  Novem- 
her  18,  19,  and  20,  1884.     Small  8vo.     Cloth,  $5.00. 

TYNDALL  (JOHN).  Essays  on  the  Floating  Matter  of  the  Air,  in  Relation  to 
Putrefaction  and  Infection.     12mo.     Cloth.  $1.50. 

ULTZMANN  (ROBERT).  Pyuria,  or  Pus  in  the  Urine,  and  its  Treatment. 
Translated  by  permission,  by  Dr.  Walter  B.  Piatt.     12mo.     Cloth,  $1.00. 

VAN  BUREN  (W.  H.).  Lectures  upon  Diseases  of  the  Rectum,  and  the  Sur- 
gery of  the  Lower  Bowel,  delivered  at  Bellevue  Hospital  Medical  College. 
Second  edition,  revised  and  enlarged.     8vo.     Cloth,  $3.00;  sheep,  $4.00. 

VAN  BHREN  (W.  H.).  Lectures  on  the  Principles  and  Practice  ot  Surgery. 
Delivered  at  Bellevue  Hospital  Medical  College.  Edited  by  Lewis  A.  Stim- 
son,  M.  D.     8vo.     Cloth,  $4.00 ;  sheep,  $5.00.  (_ 

VOGEL  (A.).  A  Practical  Treatise  on  the  Diseases  of  Children.  Translated 
and  edited  by  H.  Raphael,  M.  D.  Third  American  from  the  eighth  German  edi- 
tion, rerised  and  enlarged.  Illustrated  by  six  Lithographic  Plates.  8vo. 
Cloth,  $4.50  ;  sheep,  $5.50. 

VON  ZEISSL  (HERMANN).     Outlines   of  the  Pathology  and  Treatment   of 
Syphilis  and  Allied  Venereal  Diseases.     Second  edition,  revised  by  Maximil 
ian  von  Zeissl.     Authorized  edition.     Translated,  with  Notes,  by  H.  Ra- 
phael, M.  D.     8vo.     Cloth,  $4.00 ;  sheep,  $5.00. 

WAGNER  (RUDOLF).  Hand-Book  ot  Chemical  Technology.  Translated  and 
edited  from  the  eighth  German  edition,  with  extensive  Additions,  by  William 
Crookes.     With  336  Illustrations.     8vo.     Cloth,  $5.00. 

WALTON  (GEORGE  E.).  Mineral  Springs  of  the  United  States  and  Canadas. 
Containing  the  latest  Analyses,  with  full  Description  of  Localities,  Routes, 
etc.     Second  edition,  revised  and  enlarged.     12mo.     Cloth,  $2.00. 

WEBBER  (S.  G.).  A  Treatise  on  Nervous  Diseases :  Their  Symptoms  and 
Treatment.    A  Text-Book  for  Students  and  Practitioners.    8vo.    Cloth,  $8.00. 

WEEKS-SHAW  (CLARA  S.).  A  Text-Book  of  Nursing.  For  the  Use  of 
Traiuing-Schools,  Families,  and  Private  Students.  Second  edition,  revised 
and  enlarged.  12mo.  With  Illustrations,  Questions  for  Review  and  Ex- 
amination, and  Vocabulary  of  Medical  Terms.     12mo.     Cloth,  $1.75. 

WELLS  (T.  SPENCER).    Diseases  of  the  Ovaries.     8vo.     Cloth,  $4.50. 

WORCESTER  (A.).     Monthly  Nursing.     Second  edition,  revised.     Cloth,  $1.25, 

WYETH  (JOHN  A.).  A  Text-Book  on  Surgery:  General,  Operative,  and  Me- 
chanical.    Profusely  illustrated.     Svo.      {Sold  only  'by  subscription?) 


I 


^^Ki 


.— .-iii-.'i^t  fkf^*^^ 


